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Federal Programs and Progress 





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people! 

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U.S. Department of 
Health and Human Services 



Public Health Service 
Office of Disease Prevention 
and Health Promotion 






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PREVENTION 

^Federal Programs 
and Progress 




Office of Minority Health 

Resource Center 

PQ Box 37337 

Washington, DC 20013-7^7 



XXJU 



U.S. Department of 
Health and Human Services 

Public Health Service 
Office of Disease Prevention 
and Health Promotion 



For sale by the U.S. Government Printing Office 
Superintendent of Documents, iMail Stop: SSOP, Washington, DC 20402-9328 



Preface 



D _- 

move towards the next century, prevention will be 
the cornerstone of our Nation's reformed health 

M*MBfc» care and publk health systems [ am therefore espe- 

cially pleased to present Prevention '93f94: Federal Programs and Progress. 
It provides a comprehensive review ot the Federal Government's preven- 
tion activities. We can be proud of the scope of our efforts. 

The Department ot Health and Human Services has as one of its pri- 
orities the prevention of childhood diseases such as measles and mumps 
through age-appropriate immunizations. It also emphasizes prevention 
through the Head Start program administered by the Administration on 
Children and Families. For adolescents, we have the responsibility to 
communicate the risks of unhealthy behaviors so that they can make 
choices that will promote a long and healthy life. For adults, we must 
continue to work to reduce communicable and chronic disease. Our chal- 
lenge for older adults is to ensure that their long lives are healthy lives. 
For all age groups, we must work to reduce the terrible toll of violence. 

In many Federal agencies, prevention is a priority. The Environmental 
Protection Agency reports its efforts to prevent pollution at its source. 



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The Department of Transportation reports that traffic fatalities are at 
record lows, in part due to the increased use of child safety seats and seat- 
belts, and reductions in drunk driving. 

In the Department of Health and Human Sendees, estimated 1993 
prevention expenditures totalled more than $23 billion. Activities of the 
Public Health Service were $9.5 billion, of which $4.7 billion was spent 
on prevention research at the National Institutes of Health. Another $13 
billion of prevention expenditures were made by the Health Care 
Financing Administration for such important prevention programs as the 
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) 
program that provides early detection of childhood disease. The Head 
Start program and other programs administered by the Administration 
for Children and Families expended $445 million in direct prevention 
funding, although their indirect contributions through child develop- 
ment and social welfare are far greater than this figure. 

I believe that a healthier America is possible. We need only to set our 
priorities and devote our resources to the prevention of disease and the 
promotion of health. I commend this compendium of prevention pro- 
grams for your use and reading. 



Donna E. Shalala 

Secretary of Health and Human Sendees 



Foreword 



Prevention '93/ , 94 is the fifth biennial report of the 
Department of Health and Human Services on the pre- 
vention-related activities of the Federal Government. 
This series of reports, which began with Prevention 
'84/'85, has provided comprehensive listings of the prevention programs 
of the Department of Health and Human Services: this edition includes 
the Administration on Aging, the Administration for Children and Fami- 
lies, the Health Care Financing Administration, and the nine agencies of 
the Public Health Service. In addition, other agencies of the Federal 
Government report their prevention programs. For example, prevention 
activities are broadly defined to include environmental programs of the 
Environmental Protection Agency, the Women, Infants, and Children 
(WIC) program of the Department of Agriculture, and the Occupational 
Safety and Health Program of the Department of Labor. 

Healthy People 2000: National Health Promotion and Disease Prevention 
Objectives serves as the framework for Prevention '93/ , 94. The national 
initiative set forth in Healthy People 2000 established three overarching 
goals — increase healthy lifespan, reduce health disparities, achieve access 
to preventive services — to be achieved by the year 2000. The Nation's 



prevention agenda for improvements in public health rests on three cate- 
gories of preventive action: health promotion, encompassing both 
healthy behaviors and risk reduction; health protection, addressing 
screening as well as the physical and social environment; and preventive 
services, including immunizations, counseling, and other clinical preven- 
tive services. Within these three categories of prevention are 21 priority 
areas, which provide the substance of health promotion and disease pre- 
vention strategies. A 22nd prioritv area addresses improvements in Sur- 
veillance and Data Systems necessary for tracking progress of the 
Healthy People 2000 objectives. 

Chapter 1 of Prevention , 93/ , 94 highlights model prevention programs 
for minorities. These programs were nominated by the State HEALTHY 
PEOPLE 2000 action contacts and the minority health directors of agen- 
cies of the Public Health Service. 

Chapter 2 provides a snapshot of the health status of all Americans. 
Trends in mortality rates and the causes of deaths are examined. New tables 
have been added since Prevention '91/'92 to illustrate die differences among 
race and ethnic groups in selected causes of death. Lite expectancy by race 
and gender and years of healthy life by race anil ethnicitv are provided. 

Chapter 3 describes the prevention activities of the Department of 
Health and Human Services and other Federal departments and agencies. 

Chapter 4 displays the expenditures for prevention by the Department 
of 1 lealth and Human Services. Organized by I II \i 1 1 IV PEOPLE 2000 
priority areas, this inventor}' tracks fiscal year 1992 actual spending and 
estimated 1993 funding by agency in the Public I lealth Service and from 
the Administration for Children and Famines and the Health Care 
Financing Administration. A summary table shows block grant resources. 



Philip R. Lee, AI.D. 
Assistant Secretary for Health 



J. .Michael AicGinnis, AI.D. 

Deputy Assistant Secretary for Health 

(Disease Prevention and Health Promotion) 



o 



Table of Contents 



Foreword v 

List of Tables viii 

List of Figures viii 

Acronyms and Abbreviations ix 

Acknowledgements xiii 

For Further Information xiv 

Chapter 1 : Healthy People 2000 in 

Minority Communities 1 

Chapter 2: Health Status Trends 11 

Chapter 3: Agency Innovations 39 

Department of Health and Human Services 40 

Public Health Service 40 

Office of the Assistant Secretary for Health 40 

Agency for Health Care Policy and Research 48 

Agency for Toxic Substances and Disease Registry 51 

Centers for Disease Control and Prevention 52 

Food and Drag Administration 68 

Health Resources and Services Administration 76 

Indian Health Service 82 

National Institutes of Health 84 

Substance Abuse and Mental Health Services 

Administration 120 

Administration on Aging 125 

Adminstration for Children and Families 127 

Health Care Financing Administration 132 

Other Federal Agencies 134 

Chapter 4: OHHS Prevention Resources 

Inventory 157 

DHHS and PHS Organizational Chart Cover 3 



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List of Tables 



List of Figures 



1 . Block Grant Resources, FY 1992 and 
1993 

2. Resources for Prevention Activities, 
by Agency, Department of Health and 
Human Services, FY I'M? and 1993 

3. Resources for Prevention Activities, 
by Healthy People 2000 Priority 
Area, Department of Health and 
Human Services, FY 1992 and 1993 

4. Agencies Reporting Prevention 
Activities, by HEALTHY PEOPLE 2000 
Priority Area, Department of Health 
and Human Services, FY 1992 

5. Agencies Reporting Prevention 
Activities, by HEALTHY PEOPLE 2000 
Priority Area, Department of Health 
and Human Services, FY 1993 

6. Prevention Inventories, by HEALTHY 
PEOPLE 2000 Priority Area and 
Agency, Department of Health and 
Human Sen-ices. FY 1992 and 1993 



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Figure 1 . Death Rates for Major Causes of Death, 1980 and 1990 

Figure 2. Leading Causes of Infant Mortality, 1990 

Figure 3. Leading Causes of Death for Children Aged 1 Through 14, 1990 

Figure 4. Leading Causes of Death for Adolescents and Young Adults Aged 

15 Through 24, 1990 

Figure 5. Leading Causes of Death for Adults Aged 25 Through 64, 1990 

Figure 6. Life Expectancy at Birth, by Sex, Selected Years, 1950-1990 

Figure 7. Years of Healthy Life as a Proportion of Life Expectancy, 1990 

Figure 8. Life Expectancy and Years of Healthy Life, by Race and Hispanic 
Origin, 1990 

Figure 9. Years of Potential Life Lost (YPLL) Before Age 65, by Race and 

Sex. Selected Years, 1970-1990 

Figure 1 0. Percentage of People Experiencing Limitation of Major Activity 
Caused by Chronic Conditions, Total and Low-Income 
Populations, I983 1991 

Figure 11. Percentage oi People Experiencing Limitation ot Activity Caused 
by Chronic Conditions, by Family Income Level, 1991 

Figure 1 2. Percentage of People Experiencing Limitation of Activity Caused 

bv Chronic Conditions, by Age. 1 99 1 
Figure 1 3. Life Expectancy at Birth, by Race, Selected Years, 1950-1990 

Figure 1 4. Infant Mortality Rates, by Race and Hispanic Origin of Mother, 
1983-1987 

Figure 1 5. Death Rates for Coronary Heart Disease, by Race and Hispanic 
Origin, 1990 

Figure 1 6. Death Rates for Cancer, by Race and Hispanic Origin, 1990 
Figure 1 7. Death Rates for Stroke, by Race and Hispanic Origin, 1990 
Figure 18. Death Rates for Unintentional Injuries, by Race and Hispanic 

Origin, 1990 
Figure 1 9. Death Rates for Suicide, by Race and Hispanic Origin, 1990 
Figure 20. Death Rates for Homicide, by Race and Hispanic Origin, 1990 

Figure 21 . Death Rates for HLV Infection, by Race, Hispanic Origin, and 
Age, 1988-1990 

Figure 22. Health Insurance Coverage for People Aged 64 and Younger, by 

Type of Coverage, 1989 
Figure 23. Percentage of People With a Regular Source of Care, 1991 

Figure 24. Percentage of Pregnant Women Receiving First Trimester 
Parental Care, by Race and Hispanic Origin, Selected Years, 
1970-1990 

Figure 25. L'p-to-Date Immunization Status of School Enterers at the 
Second Birthday, United States, 1991-1992 



Acronyms and Abbreviations 




he following list of acronyms and abbreviations is 
provided as a quick index of selected terms and of 
Federal agencies, departments, offices, and 
programs that are mentioned in more than one 
instance in this publication. 



ACF Administration on Children and Families 

ACYF Administration for Children, Youth, and Families 

ADD Administration on Developmental Disabilities 

AFDC Aid to Families with Dependent Children 

AHCPR Agency for Health Care Policy and Research 

AID U.S. Agency for International Development 

.AIDS acquired immunodeficiency syndrome 

ANA Administration for Native Americans 

AoA Administration on Aging 

APA American Psychological Association 

APEX/PH Assessment Protocol for Excellence in Public Health 

APHA American Public Health Association 

ASH Assistant Secretary for Health 

ASHED AIDS School Health Education Database 

ASHP Adolescent and School Health Programs 

\SSlS I American Stop Smoking Intervention Study 

ASTHO Association of State and Territorial Health Officials 

ATF Bureau of Alcohol, Tobacco, and Firearms 

ATSDR Agency for Toxic Substances and Disease Registry 

AZT zidovudine 

BAC blood alcohol concentration 

BHPr Bureau of Health Professions 

BHRD Bureau of Health Resources Development 



e 



Acronyms and Abbreviations (cont.) 


FAS 


fetal alcohol syndrome 






FDA 


Food and Drug Administration 


BIA 


Bureau of Indian Affairs 


FDIR 


Food Distribution Program on Indian 


BJA 


Bureau of Justice Assistance 




Reservations 


BIS 


Bureau ofjustice Statistics 


FEMA 


federal Emergency Management Association 


BLSA 


Baltimore Longitudinal Study of \ 


FHWA 


Federal Highwa) Administration 


BPHC 


Bureau of Primary Health Care 


FIC 


Fogarty International Center 


BRFSS 


Behavioral Risk Factor Surveillance System 


FNS 


food and Nutrition Service 


( MIIC 


community/migrant health center 


FQHC 


Federally Qualified Health Center 


CARE 


Ryan White Comprehensive \II)S Resources 


IRA 


federal Railroad Administration 




Emergencj (( \kl 1 ^ct of 1990 


IK 


Federal Trade Commission 


CARES 


Comprehensive AIDS Reproductive Health 


FY 


fiscal year 




and Education Study 


CMP 


good manufacturing practice 


CAT( 11 


Child and Adolescent Trial tor Cardiovascular 


11ACCP 


1 lazard Analysis Critical Control Point 




1 lealth 


HBCFJ 


1 listorically Black Colleges and Universities 


CBER 


Center for Biologies Evaluation and Research 


11BV 


hepatitis 1! virus 


CCDBG 


Child Care and Development Block Grant 


1IC FA 


Health Care Financing Administration 


CDBG 


Community Development Block Grant 


1KA 


hepatitis C virus 


CDC 


Centers tor Disease Control and Prevention 


HDL 


high-density lipoprotein cholesterol 


CDER 


Center tor Drug 1 valuation and Research 


HETC 


1 lealth Education and Training Center 


CDRII 


Center tor Devices and Radiological Health 


1IIV 


human immunodeficiency virus 


( 1 S 


Cooperative Extension System 


HMO 


health maintenance organization 


CF 


cystic fibrosis 


11N1S 


1 luman Nutrition and Information Service 


( 1 SAN 


Center for Food Safety and Applied Nutrition 


HRSA 


1 lealth Resources and Sen ices Administration 


CHID 


Combined Health Information Database 


HTPCP 


1 [ealthy Tomorrows Partnership for Children 


COBRA 


Consolidated Omnibus Budget Reconciliation 




Program 




\ci of 1985 


HUD 


Department of 1 lousing and Urban 


( OMMIT 


Community Intervention Trial for Smoking 




Development 




( lessation 


1DDM 


insulin-dependent diabetes mellitus 


CPCD 


Cancer Prevention and Control Database 


IHPO 


International 1 lealth Program Office 


CPS( : 


Consumer Produci Safer) Commission 


ins 


Indian I lealth Service 


CSAP 


Center for Substance Abuse Prevention 


[MR 


infant mortality rate 


CSAT 


Center for Substance Abuse Treatment 


ixpho 


Information Network for Public Health 


( SBG 


Community Services Block Grant 




Officials 


( SS 


Clinical Support Strategy 


[OM 


Institute of Medicine 


CVI 


Children's Vaccine Initiativ e 


LDL 


low-density lipoprotein cholesterol 


CVM 


Center for Veterinary Medicine 


LI II LAP 


Low -Income 1 lome Energy Assistance 


DARE 


Drug Abuse Resistance Education Program 




Program 


DFSCA 


Drug-Free Schools and Communities Act 


MCHB 


Maternal and Child Health Bureau 


DHHS 


Department of Health and Human Services 


.\1C\ 


Migrant Clinicians Network 


DIRLLXE 


Directory of Information Resources ( inline 


MEDLARS 


Medical Literature Analysis and Retrieval 


DOC 


Department of Commerce 




System 


DOD 


Department of Defense 


MEDTFP 


Medical Treatment Effectiveness Program 


DoE 


Department of Education 


MEHP 


Minority Environmental Health Program 


DOE 


Department of Energy 


MI ITS 


Minority Health Tracking System 


DOI 


Department of Interior 


MR] 


magnetic resonance imaging 


DOJ 


Department ofjustice 


MS HA 


Mine Safety and Health Administration 


DOL 


Department of Labor 


NACAA 


National Association of Consumer Agency 


DOT 


Department of Transportation 




Administrators 


E.AP 


employee assistance program 


XACHO 


National Association of County Health 


EMS 


emergency medical services 




Officials 


EPA 


Environmental Protection Agency 


NAIEP 


National MDS Information and Education 


EPO 


Epidemiology Program Office 




Program 


EPOCH 


Educating Physicians in Occupational Health 


NAMCS 


National Ambulatory Medical Care Survey 




and the Environment 


XAPO 


Xational MDS Program Office 


EPSDT 


Early and Periodic Screening, Diagnosis, and 


NCAI 


X T ational Congress of American Indians 




Treatment Program 


NCADI 


National Clearinghouse for Alcohol and Drug 


ERG 


Emergency Response Guidebook 




Information 


ETC 


Education and Training Center 


NCCAN 


National Center on Child Abuse and Neglect 


FAA 


Federal Aviation Administration 


NCCDPHP 


National Center for Chronic Disease 


FACE 


Fatality Assessment and Control Evaluation 




Prevention and Health Promotion 




Project 


XCEH 


National Center for Environmental Health 



Acronyms and Abbreviations (cont.) 


NLM 


National Library of Medicine 






NLTN 


National Laboratory Training Network 


NCHGR 


National Center for Human Genome Research 


NMFS 


National Marine Fisheries Service 


NCHS 


National Center for Health Statistics 


NMIHS 


National Maternal and Infant Health Survey 


NCI 


National Cancer Institute 


NOAA 


National Oceanic and Atmospheric 


NCID 


National Center for Infectious Diseases 




Administration 


NCIPC 


National Center for Injur)' Prevention and 


NPS 


National Park Service 




Control 


NSFG 


National Survey of Family Growth 


NCJRS 


National Criminal Justice Reference Service 


NSLP 


National School Lunch Program 


NCPIE 


National Council on Patient Information and 


NVAC 


National Vaccine Advisory Committee 




Education 


NVPO 


National Vaccine Program Office 


NCPS 


National Center for Prevention Services 


NVSS 


National Vital Statistics System 


NCRR 


National Center for Research Resources 


OASH 


Office of the Assistant Secretary for Health 


NCTR 


National Center tor Toxiological Research 


OBRA 


Omnibus Budget Reconciliation Act 


NEI 


National Eye Institute 


OCS 


Office of Community Services 


NEISS 


National Electronic Injury Surveillance System 


OCSE 


Office of Child Support Enforcement 


NETS 


Network of Employers for Traffic Safety 


ODPHP 


Office of Disease Prevention and Health 


NETSS 


National Electronic Telecommunications 




Promotion 




System for Surveillance 


OFA 


Office of Family Assistance 


NHANES 


National Health and Nutrition Examination 


OIH 


Office of International Health 




Survey 


OJJDP 


Office for Juvenile Justice and Delinquency 


NHDS 


National Hospital Discharge Survey 




Prevention 


NHEFS 


NHANES I Epidemiologic Follow-up Study 


OJP 


Office of Justice Programs 


NHIC 


National Health Information Center 


OMH 


Office of Minority Health 


NHIS 


National Health Interview Survey 


OMHRC 


Office of Minority Health Resource Center 


NHLB1 


National Heart, Lung, and Blood Institute 


OPA 


Office of Population Affairs 


NHSC 


National Health Service Corps 


ORHP 


Office of Rural Health Policy 


NHTSA 


National Highway Traffic Safety 


ORR 


Office of Refugee Resettlement 




Administration 


OSEP 


Office of Special Education Programs 


NIA 


National Institute on Aging 


OSH 


Office on Smoking and Health 


NIAAA 


National Institute on Alcohol Abuse and 


OSH\ 


Occupational Safety and Health Administration 




Alcoholism 


ovc 


Office for Victims of Crime 


NIAID 


National Institute of Allergy and Infectious 


OWH 


Office on Women's Health 




Diseases 


PAHO 


Pan American Health Organization 


NIAJVIS 


National Institute of Arthritis and 


PATCH 


Planned Approach to Community Health 




Musculoskeletal and Skin Diseases 




Program 


NICHD 


National Institute of Child Health and Human 


PCMR 


President's Committee on Mental Retardation 




Development 


PCPFS 


President's Council on Physical Fitness and 


NIDA 


National Institute on Drug Abuse 




Sports 


NIDCD 


National Institute on Deafness and Other 


PHHS 


Preventive Health and Health Services 




Communication Disorders 


PHPPO 


Public Health Practice Program Office 


NIDDK 


National Institute of Diabetes and Digestive 


PHS 


Public Health Service 




and Kidney Diseases 


PIRC 


Preventive Intervention Research Center 


NIDDM 


noninsulin-dependent diabetes mellitus 


PPHA 


Pennsylvania Public Health Association 


NIDR 


National Institute of Dental Research 


PRB 


Prevention Research Branch 


NIDRR 


National Institute on Disability and 


PRC 


Prevention Research Center 




Rehabilitation Research 


PSC 


prenatal smoking cessation 


NIEHS 


National Institute of Environmental Health 


RADAR 


Regional Alcohol Drug Awareness Resource 




Sciences 




Network 


NIGMS 


National Institute of General Medical Sciences 


RDS 


respiratory distress syndrome 


NIH 


National Institutes of Health 


REAP 


Roof Evaluation-Accident Prevention 


NIJ 


National Institute of Justice 


RSPA 


Research and Special Programs Administration 


NIMH 


National Institute of Mental Health 


SAMHSA 


Substance Abuse and Mental Health Services 


NTNDS 


National Institute of Neurological Disorders 




Administration 




and Stroke 


SEA 


State education agency 


NINR 


National Institute of Nursing Research 


SENIC 


Study on the Efficacy of Nosocomial Infection 


NIOSH 


National Institute for Occupational Safety and 




Control 




Health 


SENSOR 


Sentinel Event Notification System for 


NIP 


National Immunization Plan or National 




Occupational Risks 




Inspection Plan 


SIDS 


sudden infant death syndrome 


NIS 


Newly Independent States 


SLE 


systemic lupus erythematosus 


NLEA 


Nutrition Labeling and Education Act of 1990 


SMZ 


sulfamethazine 



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Acronyms and Abbreviations (cont.) 

SPRANS Special Projects of Regional and National 

Significance 

SSBG Social Services Block Grant 

STD sexually transmitted disease 

TAPS Teenage Attitudes and Practices Survey 

TEAM Techniques for Effective Alcohol Management 

TPJ Toxic Release Inventory 

TSS toxic shock syndrome 

UK United Kingdom 

USAID U.S. Agency for International Development 

USDA U.S. Department of Agriculture 

LSI-' \ U.S. Fire Administration 

LA ultraviolet 

VA Department of Veterans Affairs 

YAP Vaccine Action Program 

VI IA Veterans 1 lealth Administration 

WHO World Health Organization 

WIC Special Supplemental Food Program for 

Women, Infants, and Children 

YPLL years of potential life lost 

YRBS Youth Risk Behavior Survey 



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Acknowledgements 






D - _ 

the contributions of people throughout the Federal 
Government and from many State health offices. 
■i^» ( hapter I was developed from submissions from State 

Healthy People 2000 action contacts and the minority health directors 
of agencies of the Public Health Service. Chapter 2 was developed from 
data supplied by the staff of the Health Promotion Statistics Branch, 
National Center for Health Statistics, Centers for Disease Control and 
Prevention: Alary Anne Freedman, Richard Klein, and Christine Plepys. 

Chapter 3 and the resource inventories of Chapter 4 were prepared by 
the Healthy People 2000 Steering Committee members and Healthy 
People 2000 work group coordinators. The staff of the Office of Disease 
Prevention and Health Promotion provided overall direction for this 
report. 

This document is in the public domain and may be used and repro- 
duced without further permission. Citation of the original document is 
appropriate, and the recommended citation is as follows: U.S. Depart- 
ment of Health and Human Sen-ices. Prevention '93/'94: Federal Programs 
and Progress. U.S. Government Printing Office: Washington, DC: 1994. 



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For Further Information 



Information on agency activities was supplied by the following 
people and agencies: 

U.S. DEPARTMENT OF HEALT1 1 \M> I IL'MAN SERVICES 

Public Health Service 

National Vaccine Program Office (NVPO) 

Vlarissa Miller 

I Ic.ihh Science Analyst 

Parklawn Building, Room I 1 ^56 

5600 Fishers Lane 

Rockville, MD 20876 

(301 1443-6683 

Office of Disease Prevention and Health Promotion (ODPHP) 

Deborah Maiese 

Senior Prevention Policy Advisor 

and 

Debbie Rothstcin 
Prevention Policy Advisor 
Switzer Building, Room 2132 
330 C Street. s\\ 
Washington, DC 20201 
(202)205-8583 

Office of International Health (OIH) 

Linda Vogel 

Deputy Director 

Parklawn Building, Room IS- 75 

5600 Fishers Lane 

Rockville, MD 20857 

(301) 445-1 "4 



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For Further Information (cont.) 


Food and Drug Administration (FDA) 




Peter Rheinstein, M.D. 


National AIDS Program Office (NAPO) 


Director, Medicine Staff 


Sara Henson 


and 


Assistant Director for Management and Operations 


I. David WolfsonJ.D, P.H. 


Humphrey Building, Room 738G 


Regulatory Counsel 


200 Independence Avenue, SW 


Office of Health Affairs 


Washington, DC 20201 


Parklawn Building, Room 1 5 A08 


(202) 690-6248 


5600 Fishers Lane 




Rockville, MD 20857 


Office of Minority Health (OMH) 


(301)443-5470 


Olivia Carter Pokras 




Public Health Analyst 


Health Resources and Services Administration (HRSA) 


Rockwall n Building, Suite 1 102 


Ronald Carlson 


5600 Fishers Lane 


Associate Administrator for Planning Evaluation and 


Rockville, MD 20852 


Legislation 


(301)443-8280 


and 




Lyman Van Nostrand/Melissa Hamilton 


Office of Population Affairs (OPA) 


Deputy Associate Administrator for Planning, Evaluation, 


Evelyn Kappeler 


and Legislation 


Program Analyst 


Parklawn Building, Room 14-33 


North Building, Suite 1115 


5600 Fishers Lane 


East West Highway 


Rockville, MD 20857 


5600 Fishers Lane 


(301)443-2460 


Rockville, MD 20857 




(301)594-4000 


Indian Health Service (IHS) 




Craig Vanderwagen, M.D. 


Office on Women's Health (OWH) 


Director, Division of Clinical and Prevention Service 


Susan Simmons, Ph.D., R.N. 


Parklawn Building, Room 6A55 


Humphrey Building, Room 7 3 0B 


5600 Fishers Lane 


200 Independence Avenue, SW 


Rockville, MD 20857 


Washington, DC 20201 


(301)443-4644 


(202)690-7650 






National Institutes of Health (NIH) 


President's Council on Physical Fitness and Sports (PCPFS) 


William Harlan, M.D. 


Christine Spain 


Associate Director for Prevention 


Director, Research, Planning, and Special Projects 


Building 1, Room 260 


Market Square East Building, Suite 250 


9000 Rockville Pike 


701 Pennsylvania Avenue, NW 


Bethesda,MD 20892 


Washington, DC 20004 


(301)496-1508 


(202)272-3424 






JohnT. Kalberer,Jr., Ph.D. 


Agency for Health Care Policy and Research (AHCPR) 


NIH Coordinator for Disease Prevention/Health Promotion 


Raymond Seltser, AID. 


Federal Building, Room 106 


Associate Director for Special Population Research 


7550 Wisconsin Avenue 


2101 East Jefferson, Room 502 


Bethesda, MD 20892 


Rockville, MD 20852 


(301)496-6614 


(301) 594-1349 ext. 112 






Substance Abuse and Mental Health Services 


Agency for Toxic Substances and Disease Registry 


Administration (SAMHSA) 


(ATSDR) and 


Michael C. Dana, Ph.D. 


Centers for Disease Control and Prevention (CDC) 


Senior Health Policy Analyst 


Martha Katz 


Parklawn Building, Room 12 th Floor 


Director, Office of Program Planning and Evaluation 


5600 Fishers Lane 


and 


Rockville, MD 20857 


Chris Benjamin 


(301)443-4111 


Special Assistant 




Building 1, Room 2050 




1600 Clifton Road, NE, Mailstop D-23 




Atlanta, GA 30333 




(404) 639-3243 





For Further Information (cont.) 


L T .S. Consumer Product Safety Commission 




Charles A. Nicholls 


OTHER U.S. DEPARTMENT OF HEALTH AND 


Directorate for Epidemiology 


HUMAN SERVICES AGENCIES 


5401 Westbard Avenue, Room 600 




Bethesda, MD 20816 


Administration on Aging (AoA) 


(301)504-0440 


Nancy W'artou 




Health Promotion Specialist 


U.S. Department of Defense 


Office of Program Development 


LTCRausch 


Cohen Building, Room 4269 


Senior Policv Analyst (Health Promotion) 


530 Independence Avenue. >>W 


OASD (HA)/PAQA 


\\ ashington, DC 20201 


Room 3D-366, The Pentagon 


(202)401-3098 


Washington. DC 20301-1200 




1)695-7116 


Administration for Children and Families (ACF) 




Janet llartnett 


U.S. Department of Education 


Deputj Director 


Kimmon Richards 


Office of Policy atul Evaluation 


Planning and Evaluation Service 


Aerospace Building, 7th Floor West 


400 Maryland Venue. SW, Room 5141 


570 L'Enfanl Promenade. SW 


Washington, DC 20202 


Washington, DC 20447 


(202)401-3630 


(202)401-6984 






U.S. Department of Energy 


Health Care Financing Administration 


John P. Peelers. Ph.D. 


Gerald Zelinger, M.D. 


Physical Scientist 


.Medical Advisor, Medicaid Bureau 


( kcupational Medicine Programs Division 


Fast High Rise Building, Room 2 i i 


Office of Occupational Medicine, EH-43/GTN 


6325 Security Boulevard 


Washington. DC 20585 


Baltimore, VID 21207-5187 


(301)903 5902 


(410)966-: 






U.S. Environmental Protection Agency 


Social Security Administration 


John Cross 


I lerman Grundmann 


Deputj Director, Pollution Prevention Division 


Social Science Research \n.il_v st, 'Economist 


4(11 VI Street SW. 


Office of Research and Statistics 


Washington, DC 20460 


Division of Statistics Analysis 


(202)260-3559 


4-C-15 Operations Building 




6401 Security Boulevard 


Federal Emergency Management Agency 


Baltimore. MD 21235 


Morris Boone 


(410)965-0183 


Office of Public Affairs 




500 C Street S.W., Room 820 


OTHER DEPARTMENTS AND AGENCIES 


Washington, DC 20472 


OF THE FEDERAL GOVERNMENT 


(202)646-4600 


U.S. Department of Agriculture 


Federal Trade Commission 


Debbie Masse] 


Dana Rosenfeld 


Assistant to the Deputv Administrator 


Assistant to the Director. Bureau of Consumer Protection 


Special Nutrition Programs 


Room 466, 6th Street and Pennsylvania Avenue, NW 


Food and Nutrition Ser\-ice 


Washington, DC 20580 


3101 Park Center Drive Room 510 


(202)326-2113 


Alexandria, Virginia 22302 




(703) 305-2054' 


U.S. Department of Housing and Urban Development 




Edwin Stromberg 


U.S. Department of Commerce 


Program Manager 


Bruce C. Moreland 


Division of Affordable Housing and Technology Research 


Chief, Utilization Research and Services Division 


Room 8126 


National Marine Fisheries Service 


Office of Policy Development and Research 


1335 East- West Highway 


45 1 7th Street, SW 


Silver Spring, Maryland 20910 


Washington, DC 20410 


(301)713-2358 


(202)708-4370 



ffijj 



For Further Information (cont.| 


U.S. Department of Treasury 




Diane Fletcher 


U.S. Department of Interior 


Consumer Representative 


Carl Bishop 


and 


Bob Garbe 


Jerry D. Bowerman 


Safety and Occupational Health Office 


Chief, Special Programs Branch 


Box 25007 (D-l 15) 


Industry Compliance Division 


Denver, CO 80225 


Bureau of Alcohol, Tobacco and Firearms 


(303)231-5208 


650 Massachusetts Avenue, NW 




Washington, DC 20226 


U.S. Department of Justice 


(202)927-8120 


Robert Brown 




Chiet of die Special Programs Division 


U.S. Department of Veterans Affairs 


Bureau of Justice Assistance 


Pamela Steele, M.D. 


Office of Justice Programs 


Director, Preventive Medicine Program 


lOdi Floor, Room 1042 


Clinical Programs 


633 Indiana Avenue 


and 


Washington, DC 20531 


David H. Law, M.D. 


(202)514-5943 


Deputy Associate Deputy Chief 




Medical Director for Hospital Based Services 


Laura Lewis 


Medical Service (1 1 1A) 


(202) 307-5966 


810 Vermont Avenue, NW 


and 


Washington, DC 20420 


Terrence S. Donahue 


(202) 535-7577 


Director 




Office of Planning, Management, and Budget 




Office of Justice Programs 




Washington, DC 20531 




(202) 307-5066 




U.S. Department of Labor 




Robert Copeland 




Director, Office of Regulatory Economics 




Room S-2312 Perkins Building 




200 Constitution Avenue NW. 




Washington, DC 20210 




(202)219-6197 




U.S. Department of State 




Douglas Proops, M.D. 




Assistant Medical Director 




Environmental Health and Preventive Medicine 




Office of Medical Services 




Washington, DC 20520-2256 




(202)647-5337 




U.S. Department of Transportation 




Robert D. Nutter 




Chief, Industry Operations and Safety Division 




Office of Transportation and Regulatory Affairs 




Room 92 1 6, Code P- 13 




Nassir Building 




400 Seventh Street, SW 




Washington, DC 20590 




(202)366-2916 





^^ft 



Chapter 



Healthy People 
Communities 



IT 

■^hsks^D EALTHY PEOPLE 2000 set the Nation's preven- 
tion agenda for improving the health of all 
Americans. It challenged us to focus on disease 
c^mI^m ^^fl^^M prevention and health promotion efforts 

HEALTHY PEOPLE 2000 committed the Nation to attain three broad 
goals: 

• Increase the span of healthy life for Americans, 

• Reduce health disparities among Americans, and 

• Achieve access to preventive services for all Americans. 

The second goal, which recognizes that the health of a Nation is mea- 
sured by the status of all its people, is the focus of this first chapter of 
Prevention '93/'94, 

The disturbing inequalities in health status among diverse racial and 
ethnic population groups were recognized in the analysis of data from track- 
ing the 1990 objectives. From the 1990 process, we learned that the provi- 
sion of preventive services "did not translate proportionately into achieve- 
ments among the health status objectives. . . [for] all groups equally." ' There 



1 J. Michael McGinnis, M.D., et. al„ Health Progress in the United States, Results of the 1990 Ob- 
jectives for the Nation, Journal of the American Medical Association, November 11,1 992. 



Prevention '93/'94: Federal Programs and Progress 



arc continuing disparities in health indicators for various pop- 
ulation groups. For example, blacks at birth in 1990 did not 
share the same life expectancy as whites and Hispanics. Pre- 
mature deaths horn heart disease. Stroke, cancer, diabetes, and 
violent injury decrease black life expectancy. For American In- 
dians and Alaska Natives, diabetes, cirrhosis, and injuries are 
the leading causes of premature death. For Hispanics, deaths 
from diabetes, homicide, and H1Y infection are higher. One 
contributing factor to the differences in lite expectancy could 
be the continuing gap in access to health insurance. While 
14.5 percent of whites lacked coverage, more than 20 percent 
of minority populations were without health insurance cover- 
age. \s a Nation, we nuuA to recognize where disparities exist 
and to take effective steps to reduce and eventually eliminate 
those differences through prevention. 

In tact, the "second goal addresses the greatest failures ol 
the 1990 objectives — those for improving the health of histor- 
ically disadvantaged populations."- Therefore, as the 500 

111 U I I IV PEOPl I 20(10 objectives were developed, considera- 
tion was given to setting specific targets lor population groups 
known to be at higher risk tor death, disease, injury, or disabil 
it)'. Altogether, some 225 specific population targets were set 
foi American Indians and Alaskan Natives, Asian and Pacific 
Islander Americans, African Americans. Hispanic Americans, 
people with disabilities, ami people with low incomes. 

The most current data reported in the first round ot 
III \l 111V PEOPL1 2000 Progress Reviews and Health, United 
States, 1993 and Healthy People 2000 Rein;:: 1993 indicate that 
we are making progress toward many of the specific popula- 
tion targets. In order to achieve all of the year 2000 targets for 
specific population groups, prevention activities must locus on 
the health concerns specific to minority groups. The federal 
( Jovernment cannot act alone. State and local governments, as 
well as businesses and community organizations, need to be 
invoked m assessing the health status of their residents, un- 
dertaking outreach activities, developing culturallj sensitive- 
education materials, and implementing quality prevention 
programs. 

The Public Health Service (PHS) is conducting HEALTHY 
2000 specific population cross-cutting progress re 
\ lews that assess the efforts of PI IS agencies. At these sessions, 
the current health status of a specific population group is pre- 
sented, with discussion focusing on strategies to improve 
health and alleviate barriers in achieving certain HEALTHY 
PEOPLE 2000 objectives. Overcoming these barriers requires 
solutions that include, but are not limited to, developing sup- 
plements to national data sources through State data systems 
and model standards approaches. It also demands the contin- 
ued commitment ot States, communities, and the PHS. 
Healthy People 2000 objective 8.1 1 calls for us to "increase 
to at least 50 percent the proportion of counties that have es- 
tablished culrurallv and linguisticallv appropriate community 
health promotion programs for racial and ethnic minority 
populations." 

To learn about many prevention activities that are under- 
way throughout the country, the HEALTHY PEOPLE 2000 
PHS Steering Committee and State Action contacts identi- 
fied model programs. These initiatives aim to reduce health 
disparities among different racial and ethnic populations. 
The representative programs highlighted here are funded by 



PI IS agencies. State health departments, and local sources of 
support. 



2 Ibid. 



African Americans 

The Comprehensive Health Improvement Project 
(CHIP) in Martin County, Florida, focuses on reducing 
morbidity and mortality rates from chronic diseases (heart dis 

ease, stroke, cancer, diabetes, and chronic lung disorders) in 
African American women. First, an advisor) committee of 
African American women was formed b) CHIP. With the 
committee's assistance. CHIP sponsored two community 
health fairs offering health screenings, risk appraisals, and 
counseling; conducted a health needs assessment survey ol 
M'rican American women in the county; asked each black 
church to incorporate health messages in Sunday church bul- 
letins; offered quarterly smoking cessation classes and 
monthl) weight loss, cholesterol, and hypertension classes; 
and obtained, with the help ol the \merican Cancer Society, 
free mammograms for low-income women. Contact: Cathy 
Cottle. Health and Rehabilitation Services, Martin County 
Public Health Unit, 620 South Dixie Highway, Stuart, IT 
34994. Telephone: (407) 22 1-4090. 

In 1986, the Indiana State Department of Health, in collabo- 
ration with Indiana Black Expo, began the Black and Minor- 
ity Health Fair. Participation and funding for this event come 
from a variety ol sources, including health care providers, cor- 
porations, and media. In 1993, over 48 different booths of- 
fered screenings, educational materials, counseling, and refer- 
rals at this 5-day health event, and over 6,200 screenings were 
completed. A stage was also incorporated into the 1 lealth Pair, 
and over 20 participants entertained and educated the crowd 
on health related issues. Contact: Cathy Archev, Office for 
Special Populations, Indiana State Department of Health, 
P.O. P-ov 1964, Indianapolis, IX 46206-1964. Telephone: 
(317)633-0607. 

Project LifeEeat, coordinated by the Wayne Count)' Health 
Department in Michigan, seeks to reduce cardiovascular dis- 
ease and stroke in the African American community. Sixty-two 
Detroit and Wayne County community organizations formed 
a coalition to undertake community outreach, risk appraisal/ 
screening, health promotion/risk reduction, nutrition/weight 
control, and medical referral. Approximately 5,500 people 
were screened, 64 percent at a community site and 36 percent 
at worksites. 1 he majority ot people (68 percent) had learned 
about the program by word of mouth. Beliefs and attitudes 
about risks were surveyed. Most respondents knew about the 
risks and were willing to work at reducing the risk factors. 
Contact: Cynthia Taueg, R.N., M.P.H., Health Officer, 
Wayne County Health Department, 2501 S. Merriman Road, 
Westland, MI 48185. Telephone: (313) 467-3300. 

In Cleveland, Ohio, the Mt. Sinai Medical Center collabo- 
rated with inner city churches to create the Mt. Sinai Church 
Hypertension Control Program, which serves predomi- 
nantly black, low-income individuals. Selected church mem- 
bers were trained in offering blood pressure monitoring and 
cardiovascular risk-reduction information. Hypertension pro- 
grams also were established within the participating black 



Healthy People 2000 in Minority Communities 



churches. As result of this program, blood pressure control 
rates of around 78 percent have been achieved consistently, up 
from a baseline of approximately 39 percent. Contact: Jovce 
Lee, R.N., M.A. Mt. Sinai Medical Center, One Mt. Sinai 
Drive, Cleveland, OH 44106. Telephone: (216) 421-4280. 

The REACH Futures Project located in Chicago, Illinois, is 

an innovative service initiative designed to prevent maternal and 
infant mortality and morbidity in a low-income, urban commu- 
nity. Extensively trained community residents, under the super- 
vision of maternal and child nurses, provide home visits to 
mothers with infants to promote and maintain health, provide 
culturally sensitive parenting education, and assist families in 
accessing support and social services. The trained residents are 
employed bv this community-based university program and in- 
teract with families in the community, hospitals, and primary 
care environments. The model is described as one that empow- 
ers both the workers and the families they serve. Contact: Cyn- 
thia Barnes-Boyd, Ph.D., 2045 West Washington Boulevard, 
Chicago, IL 60612. Telephone: (312)413-7810. 

The Positive Emotional Capacity Enhancement Training 
Project sponsored by the Ohio Commission on Minority 
Health addresses for African American youth their dispropor- 
tionate risk for morbidity and early mortality resulting from 
violence. Culturally specific violence prevention projects have 
demonstrated success in pilot initiatives offering education 
and skills development to modify the attitudes and behavior of 
potential disputants. Contact: Cheryl Boyce, Executive Direc- 
tor, 77 South High Street, Suite 745, Columbus, OH 43266- 
0377. Telephone: (614) 466-4000. 

The Newark Community Health Center in New Jersey 
started an Obesity Program or Feeling Good About Your- 
self Club due to the high incidence of obesity in the commu- 
nity (80 percent of African Americans/20 percent of Hispanic 
Americans). The support group was designed to assist obese 
patients in developing self-esteem and weight control and to 
provide health education. Contact: Dr. Anita Vaughan, Med- 
ical Director, 101 Ludlow Street, Newark, NJ 07114. Tele- 
phone: (201) 565-0355. 

Health Is Life is a demonstration health promotion and dis- 
ease prevention program of the National Urban League. 
Community-based organizations use local resources to en- 
hance the knowledge of low-income and minority consumers, 
particularly African Americans, about the importance of diet 
as it relates to health. The program uses low- literacy and cul- 
turally sensitive materials and tailored dissemination tech- 
niques that focus on diet, health, and the comprehension of 
food labels. Contact: Monique Nero, 500 East 62nd Street, 
New York, NY 10502. Telephone: (212) 310-9107. 

The Missouri Gateway Geriatric Education Center is in- 
volved in several projects serving the health needs of the elderly. 
One project, in collaboration with the Housing Authority of 
East St. Louis, trains medical students to carry out geriatric as- 
sessments for older African Americans. This center is one of a 
network of geriatric education centers that develop new curric- 
ula, training materials, and clinical training sites. Contact: John 
Morley, MJD., 1402 South Grant Boulevard, Room M238, St. 
Louis,MO 63104. Telephone: (314) 577-8462. 



The SIMBA program (Saturday Institute for Manhood, 
Brotherhood Actualization) addresses the problem of the 
high death rate among young African-American males due to 
violence and health-related issues. Based in Atlanta, Georgia, 
the program provides incarcerated youth aged 9 to 17 with a 
variety of Saturday classes in health education, violence pre- 
vention, stress management, African American history, voca- 
tional development, and aesthetic arts (photography, silk 
screening, drama, music, and video development). SIMBA also 
provides follow-up services in job placement after these youth 
are released. SLVIBA is a consortium consisting of the Wholis- 
tic Stress Control Institute (WSCI), the Lorenzo Benn Y r outh 
Development Center, and 10 other community organizations. 
Contact: Jennie C. Trotter, Executive Director, WSCI, 3480 
Greenbriar Parkway, Suite 310-B, Atlanta, GA 30331 or P.O. 
Box 4248 1 , Atlanta,' GA 303 3 1 . Telephone: (404) 344-202 1 . 

The Southwest Coalition With Youth and Westside 
Health Services are developing a community health outreach 
model to reach minority males, especially African American 
males aged 15 to 19, in the southwest Rochester, New York, 
area. This program employs at-risk African American youth as 
health outreach workers in the community. Health education 
and promotion activities take place at community events, 
housing projects, and soup kitchens, as well as through home 
visits. Contact: Jerald Noble, Project Coordinator, Westside 
Health Services Inc., 480 Genesee Street, Rochester, NY 
1461 1. Telephone: (716) 436-3040. 

West Dallas Community Centers, Inc., operates a primary 
alcohol and other drug abuse prevention demonstration pro- 
ject that targets 50 African American high-risk youth aged 6 to 
12. The program uses an innovative approach called the Rites 
of Passage. The Rites of Passage curriculum includes units on 
family histories of the African people, sex education, spiritual- 
ity, personal hygiene, housekeeping and finances, assertive- 
ness and leadership, values clarification, future planning, time 
management, art and dance, street survival, and physical con- 
ditioning. The program began in September 1990 and oper- 
ates from five community centers in West Dallas, Texas, 
neighborhoods. The Rites of Passage curriculum reduces the 
risk for alcohol and other drug use by improving self-concept, 
cultural competence, and academic performance. Contact: 
Zachary S. Thompson, West Dallas Community Centers, 
Rites of Passage Program, 8200 Brookriver Drive, Suite N- 
704, Dallas, TX 75247. Telephone: (214) 630-0006. 



American Indians and 
Alaska Natives 

The Minnesota Department of Health Diabetes Control Pro- 
gram has funded programs established within primary care or- 
ganizations to delay or prevent the onset of diabetes complica- 
tions. In the five funded clinics, American Indians make up 
about 40 percent of those served. One of the grant recipients, 
the Indian Health Board of Minneapolis, Minnesota, is pi- 
loting a new strategy combining outreach with a computerized 
tracking and recall system. An increase in the number of peo- 
ple receiving eye and foot examinations has been found in ini- 
tial evaluations of this strategy. Contact: Cindy Clark, Dia- 
betes Unit, Minneapolis Department of Health, 717 



Prevention '93/94: Federal Programs and Progress 



Southeast Delaware Street. P.O. Bo\ 9441, Minneapolis. MX 
55440-9441. Telephone: (612) 623-5287 

In Anchorage, Alaska, the Rural Alaska Community Action 
Program, Inc. (RurAL CAP), administers a project based in 
Fort Yukon, Alaska, that teaches Athabascan youth aged 7 to 
IS traditional subsistence skills such as sewing-, trapping, hunt- 
ing, fishing, and food preparation. This Fort Yukon Youth 
Survivors' Project also provides opportunities for commu- 
nity members to participate in native cultural activities and 
sponsors workshops and training events to address alcohol and 
drug use. Following its completion and evaluation, this model 
high-risk youth demonstration project may be replicated in 
more than $00 Alaska Native villages. Contacts: Nancy James, 
Project Coordinator, Fort Yukon Youth Survivors, P.O. Box 
". Fun Yukon, AK 99740, Telephone: (907) 662-2705; and 
David Hardenbergh, Program Director. RurAL CAP Preven- 
tion Program. P.O. Box 20098, Anchorage. \K 99520, 1 ele 
phone: (907) 279-2511. 

In North Dakota, the Three Tribes ProgTam incorporates 
traditions and beliefs ol the Name American community into 
the program's cancer prevention and intervention activities. 
This program ol the Three Tribes Health Services and the 
State health department has established a unit ol the American 
Cancer Societ) on a reservation, conducted a [992 tribal em- 
ployee smoking cessation program, and formed the group 
STOMP (Stop Tobacco Opportunities lor Minors). Contacts: 
Barbara Burgum Lee, Cancer Program Coordinator, North 

Dakota Stale Department of Health, 600 East Boulevard Av- 
enue, Bismarck, ND 58505, Telephone: (701) 224-2333; and 
Susan Paulson. M.P.I I., Health Educator, Minne-Tohe 
Health Center, Highwaj 23 and Four Bears. P.O. Box 400, 
New [own, \D 58763, Telephone: (701) 627-3450. 

Project Nammy, located on the (row (reek Indian Reser- 
vation in South Dakota, provides mammography screening 
to reservation women aged 55 and older. In the first year ol 
the pilot program, "5 percent of the targeted women received 
mammograms. General education about a variety of health is- 
sues is also provided. Subjects include pap smears, rectal ex- 
aminations, diabetes screening, and adult immunizations. 
Contact: Margaret Brown. B.S.. R.N. P.O. Box 200, Ion 
Thompson. SI) 57339. Telephone: (605) 245-2285. 

In Wagner, South Dakota, efforts have been made through 
the Wagner Service Unit Diabetic Program to address the 
high level of Type II diabetes mellitus in the Yankton Sioux 
Tribe. A multi-disciplinary team, consisting of dietitians, 
nurse educators, and physicians, regularly provides outpatients 
of all ages with preventive care such as pelvic, breast, foot, and 
rectal examinations. Contact: Colleen Permann, R.N., 
C.D.E., Wagner Indian Health Service Hospital, P.O. Box 
490, Wagner. SD 5~380. Telephone: (605) 384-3894. 

The Arizona Disease Prevention Center, located at the 
L niversity of Arizona Health Sciences Center in Tuscon, tar- 
gets Mexican American and Yaqui Indian women in its activi- 
ties to address breast and cervical cancers and cardiovascular 
disease. The center's goals are to develop, evaluate, and dis- 
seminate health assessments and interventions related to in- 
creasing screening rates for these conditions in women aged 



40 and older and to add to the research base tor health promo- 
tion and disease prevention by investigating the cultural be- 
liefs, attitudes, and knowledge about health and chronic dis- 
ease in these populations. A unique feature of the program is 
that the interventions are delivered by trained peer health ed- 
ucators. Contact: Thomas Edward Moon, Ph.D., Principal In- 
vestigator, University of Arizona Health Sciences Center, 
1501 North Campbell Avenue, Tucson, AZ 85724. Tele- 
phone: (602) 626-4010. 

The Window Rock and Chinle Driving Under the Influ- 
ence (DUI) Project in Arizona targets third-time DU] of- 
fenders with interventions such as family counseling and con- 
frontation services. At the Chinle project, a traditional tribal 
Peacemaker is also employed. At the conclusion of this project, 
an analysis will be done CO assess which method of intervention 
is the best deterrent to DU] crimes. Contact: LaYerne D. 
Yazzie, Executive Director, Division of Health, P.O. Box 709, 
Window Rock, AZ 865 15. Telephone: (602) 87 1-69 19. 

The Family-Centered, Coordinated Early Intervention 
Sv stems lor Navajo ( Ihildren and Families Project of Utah 

Stale I Diversity works to improve the health and develop- 
mental status ol young Navajo children with special health 
care needs ami to prevent infant mortalit) and morbidity in 
three locations in the Navajo Nation through the establish- 
ment of family health and development centers and a pareni 
to-parent network. Contact: Richard Roberts, Ph.D., Co-Di- 
rector. Utah State University, Logan. UT 84322-6580. 
Telephone: (801) 750 5346. 

The National Native American AIDS Prevention Center 

administers community-based programs in Anchorage, Hon- 
olulu, Kansas City, Oklahoma City, Phoenix, Seattle, 
Pembroke (North Carolina), and Pauma Valley (Califor- 
nia). I 'hese programs offer ease management and client advo- 
cacj services to asymptomatic and symptomatic Native Amer- 
icans with HIV. Services include medical, psychosocial, and 
practical support. I be project's goals are (1) to improve access 
to services lor Native Americans with 1 1 1 \ . (2) to improve 
their quality of life, ami (5) to improve the ability ol agencies 
and local services providers to serve their clients. Contacts: 
Ron Rowell, National Native American AIDS Prevention 
Center, 5515 ( Jrand Avenue. Suite #100, Oakland, CA 94610; 
and Jay Johnson, National Native American MDS Prevention 
Center. 205 West 8th Street. Lawrence. KS 66046. 

The Milwaukee Indian Health Center in Wisconsin has 

developed a program to prevent and reduce infant mortality 
and birth defects by providing comprehensive care to Ameri- 
can Indian women. Care includes risk assessments, prenatal 
medical and nursing services, nutrition and social services, and 
parenting and nurturing classes. Contact: William Erwin, Ex- 
ecutive Director, 930 North 27th Street, Milwaukee, WI 
53208. Telephone: (414) 931-81 1 1. 



Asian and Pacific Islander 
Americans 

In 1991, Health Start began as a prevention partnership 
among the Guam Department of Education, the University of 



Healthy People 2000 in Minority Communities 



Guam, and the Department of Public Health and Social Ser- 
vices. That pilot program addressed childhood obesity. The 
program expanded into an island-wide elementary school pro- 
ject in 1992. Some 900 children have been tested for their 
knowledge of nutrition and measured for height, weight, and 
body fat. Parents were informed ot the findings and were of- 
fered free group counseling. Additionally, the program pro- 
vided school curriculum modification and teacher and food 
service worker training. Teachers, counselors, school health 
nurses, and food service workers were trained in the program. 
In the 1992-93 school year, the program expanded to all pub- 
lic elementary schools and became known as Healthy Begin- 
nings. Contact: Lisa Gemo, R.D., Nutritionist III, Depart- 
ment of Public Health and Social Services, Government of 
Guam, P.O. Box 2816, Agana, GU 96910. Telephone: (671) 
734-4589 ext. 316 and FAX (671) 734-5910 

The word AKAMAI is a Hawai'ian word meaning smart. In 
the context of the AKAMAI Youth Project, it stands for Ac- 
quiring Knowledge, Awareness, Motivation, and Inspiration. 
This project works with at-risk youth identified by the police 
as status offenders, such as runaways, curfew violators, or 
youth bevond parental control. Twenty-five government and 
community services organizations collaborate in this partner- 
ship. The youth, the majority of whom are Hawai'ian/part 
Hawai'ian, are offered a variety of services, including family 
counseling, workshops, and anger management. Topics such 
as teen pregnancy, sexually transmitted diseases, and alcohol 
and other drug use are addressed through these services. The 
goal of the program was to reduce recidivism among runaway 
youth from 60 percent to 45 percent. Among the initial 600 
students participating in this program, the recidivism rate was 
only 16 percent. Contact: Major David Benson, Honolulu Po- 
lice Department, 801 South Beretania Street, Honolulu, HI 
96813. Telephone: (808) 943-3915. 

Another exemplary youth project in Havvai'i is Teen 
C.A.R.E., a school-based substance abuse treatment program 
located on five public school campuses in O'ahu. At each site, 
two full-time substance abuse counselors work with students 
identified as substance abusers, helping students become and 
remain abstinent from all drug or alcohol use. The success of 
supporting long-term student abstinence is attributed to the 
development of trust among the students and school staff. 
Contact: Bonnie Cordeiro, Teen C.A.R.E. Program Director, 
43 Oneawa Street, #204, Kailua, HI 96734. Telephone: (808) 
261-4458. 

The Southeast Asian Community Health Needs Assess- 
ment Project surveyed the health and behavioral characteris- 
tics ot the Hmong and Laotian population residing in North- 
east Detroit, Michigan. Approximately 500 Hmongs, people 
of Laotian descent, completed a questionnaire that addressed 
their feelings about health. Contact: Connie Alfaro, Office of 
xVIinority Health, Michigan Department of Public Health, 
3423 North Logan/Martin Luther King Jr. Boulevard, P.O. 
Box 30195, Lansing,MI 48909. Telephone: (517) 335-9079. 

The National Association of Asian American Women 

(NAP AW) and the Food and Drug Administration (FDA) con- 
ducted two health and nutrition workshops. The first educated 
women about menopause, and the second looked at the nutrient 



needs of women, with special attention to the new food label. 
The workshops were a part of a major conference held on May 
19-20, 1993, in Bethesda, Maryland, to increase awareness of 
important health issues for Asian American and Pacific Islander 
women. Contact: Vivian Kim, P.O. Box 0494, Washington 
Grove, MD 20880-0494. Telephone: (301) 443-4447. 

Chinatown Health Clinic (a.k.a. Chinatown Action for 
Progress, Inc.) was founded in 1971 to meet the health needs 
of a growing Chinese community in New York, New York. 
Bilingual and bicultural staff provide primary health care ser- 
vices, including pediatrics, internal medicine, prenatal care, 
OB/GYN, other medical specialties, pediatrics dental screen- 
ing, annual flu shot program, and clinical screening programs 
for hepatitis, intestinal parasites, tuberculosis, and thalassemia. 
Bilingual health education sendees include an annual outdoor 
health fair, a weekly radio program on preventive health, a 
monthly radio health hotline program, periodic newspaper ar- 
ticles on a variety of health topics, development and dissemi- 
nation of bilingual health education pamphlets, and on- 
site/off-site workshops on parenting skills, prenatal and 
postnatal care, infant care, nutrition, women's health, 
HIV/MDS prevention, adolescent sexuality, and family plan- 
ning. Contact: Harold Lui, Executive Director, 89 Baxter 
Street, New York, NY 10013. Telephone: (212) 233-5059. 

The International District Community Health Center — 
Hepatitis B Demonstration in Washington State seeks to 
improve Asian/Pacific Islanders' understanding of disease pre- 
vention measures, including vaccination goals, through com- 
munity media, community organizations, activities in schools, 
and physicians serving the Asian community. Contact: 
Dorothy Wong, International District Community Health 
Center, 416 Maynird Avenue, South, Seattle, WA 98104. 
Telephone: (206)' 46 1-3 6 17. 

The Southeast Asian Regional Community Health 
(SEARCH) Project addresses the weakened health status 
among Cambodian, Hmong, Laotian, Vietnamese, and Chi- 
nese mothers and their children who are refugees and recent 
immigrants in Columbus and Toledo, Ohio, and Detroit, 
Michigan. The general under-utilization of preventive health 
care is a major concern. The strength of the project is its coor- 
dination of community-based expertise and existing services 
for the provision of culturally appropriate services. SEARCH 
maximizes its potential through constant community input on 
the design of services. Contact: Elizabeth Chung, SEARCH 
Project Director, Ohio Commission on Minority Health, 77 
South High Street, Suite 745, Columbus, OH 43266-0377. 
Telephone: (614) 466-4000. 



Hispanic Americans 

The South Texas Geriatric Education Center (STGEC) 

targets 185 counties, both urban and rural, whose populations 
include large numbers of elderly Mexican Americans. STGEC 
is also the geriatric training arm tor both the South Texas 
Area Health Education Center and the Health Education 
Training Centers Alliance of Texas. STGEC provides educa- 
tion in geriatrics and gerontology to faculty and health profes- 
sionals, including those who treat underserved elders in all 



J 



Prevention ' 9 3 / ' 9 4 : Federal Programs and Progress 



public health service sites. Disease prevention and health pro- 
motion projects include (1) an award-winning videotape and 
handbook in both Spanish and English on oral care of med- 
ically compromised elders lor nursing assistants and other 
caregivers, (2) a series of seven video novellas to assist low-lit- 
eracy Hispanics in managing their diabetes, and (3) .\n educa- 
tional intervention directed at physicians who treat Mexican 
American elders to increase the use of influenza vaccine. Con- 
tact: Vlichele Saunders. D.M.D.. M.S.. M.F.I I.. 7703 Floyd 
Curl Drive. San Antonio. IX 78284-7921. Telephone: (210) 
567-3370. 

Saint Joseph's Hispanic Services in Atlanta. Georgia, pro- 
vides primary care and health care access assistance to 1 [ispanic 
families who have recently immigrated to the Atlanta area and 
have limited English language skills. Services include volun- 
teer-staffed evening primary care clinics, perinatal anil general 
health education. 1IIV ami alcohol risk prevention programs. 
Support groups tor abused women, assistance to families ol 
children with disabilities, and coordinated support to health 
care providers regarding cultural issues affecting the health ol 
Hispanic families. Contact: Sister Barbara Harrington. Sail : 
Joseph's Hispanic Services, 5665 Peachrree Dunwood) Road 
NE., Atlanta, GA 30342-1701. Telephone: (404) 851-7778. 

I In Cuidate Mujer: Prevention and Treatment of Sub- 
stance \buse Among High-Risk Hispanic Women in 
Hartford. Connecticut, is a demonstration initiative of the 

llisp.mic Health Council designed to reduce the number of 
pregnant I [ispanic women engaged in substance abuse and, in 
turn, to reduce the number of infants with in utero exposure to 
harmful chemical substances. Combining case finding, case 
management, a culturally targeted sell-help group, and client 
advocacy with prevention education, follow-up, and day treat- 
ment, the program otters direct services, education, outreach, 
ami follow-up for up to 500 Hispanic women who are at risk 
for substance involvement or are already addicted. An original 
bilingual, bicultural curriculum has been generated. Contact: 
Elizabeth Toledo. The Cuidate Mujer: Prevention and Treat- 
ment ot Substance Abuse Among High-Risk Hispanic 
Women. Hispanic Health Council, 98 Cedar Street, Hart- 
ford. CT 06106. "Telephone: (203) 527-0856. 

El Centro Hispano/The Hispanic Center in Indianapolis, 
Indiana, is a multi-service center that otters various health care 
services, including a WIC clinic, immunizations, a well-baby 
clinic, anonymous/confidential HIY testing, and health screen- 
ings such as glucose, cholesterol, high blood pressure, and lead 
poisoning. The Hispanic Center also has an outreach program 
targeted at Latinos at risk for HIV/AIDS, substance abuse, and 
sexually transmitted diseases. This program includes 
HIY/AIDS prevention education presentations, home visits, 
and a Latino Youth HIV/AIDS Peer Education program. The 
Hispanic Center also holds an annual health fair, "Feria de la 
Salud," for the Latino community. The event usually attracts 
over 250 people. Contact: Maria E. Howard, 617 E. Xorth 
Street. Indianapolis, EX 46204. Telephone: (317) 636-6551. 

Organizacion Civica y Cultural Hispana Americana 
(O.C.C.H.A.) is a community-based organization in Ohio 
that focuses on AIDS education. Activities conducted by this 
program are person-to-person outreach and workshops within 



the Hispanic community, distribution of information in Span- 
ish and English for youth and adults, and an VI DS education 
program targeted to Hispanic women through "safer sex" 
home parties. Contact: Mary lsa Garayua, 10 South Fruit 
Street. Aoungstown, OH 44506. 'Telephone: (216) 744-1808. 

ProyeCtO de HEPA is aimed at elementary school (fourth- 
sixth grade) students and their parents in Puerto Rico. Chil- 
dren are taught to communicate with their health care 
provider using elementary rules such as talk, listen, ask ques- 
tions, learn, and decide what CO do in a real situation. The 
word HEPA stands for heblar escuchar, preguntar, and apren- 
der in Spanish. Students are exposed to patient drug informa- 
tion and health maintenance concepts. The children attend a 
health care screening. Contact: Dr. Rita Osorio, 289 Winston 
Churchill Avenue El Seniorial, Rio Piepras, PR. Telephone: 
761-3423. 

■j I.a Familia Sana is a project conducted by l.a Clinica Del 
Carino in Hood River, Oregon, that promotes pediatric and 
adult health among 1 lispanic migrant and seasonal farm work- 
ers. Preventive services, innovative health services, and health 
education are delivered by community health promoters from 
the community. The project focuses in particular on chemical 
dependency, adult chronic disease, depression and psychoso- 
cial stress, occupational health, and lack ol access to health 
care. Contact: Noel Wiggins. 2690 May Street, P.O. Box 800, 
Hood River, OR 97031. Telephone: (503) 586 4880. 

l.a Nueva Vula. Inc., had a project named Comanidad Y 
Cultura in Santa Fe, New .Mexico. This project hopes to re- 
duce the health and social risks of Hispanic males through 
workshops with at-risk Hispanic males aged 12 to IS. Train- 
ing ami cultural participation through workshops that empha- 
size the rich New Mexico culture are used as vehicles tor in- 
tervention. The core management teams consist of an 
intergenerational network of role models, workshop teachers 
recruited from the community, and experienced professionals 
m counseling and community development. The "Com- 
padrazgo .Model" has been adapted lor the program, and 18- 
in 24-year-olds become part ot the Leadership Training 
1 earn. These voting adults assume a leadership role for the at- 
risk 12- to 18-year olds. Contact: Gar) (.iron, Executive Di- 
rector. P.O. box 5739, Santa Fe, N.\l 87502-5739. Tele- 
phone: (505) 983 9521. 

Para Vivir Bien is conducted by the National Coalition of 
Hispanic Health and Human Services Organizations 
(COSSMHO) to design nutrition education materials based 
on the Dictmy Guidelines for Americans. The goal of this pro- 
gram is to raise awareness of nutrition in the Hispanic com- 
munity through culturally appropriate information. Contact: 
Carlos Vegas, 1501 16th Street NW'.. Washington, DC 
20036. Telephone: (202) 387-5000. 

Escuelita Substance Abuse Primary Prevention (EPP) in 
San Antonio, Texas, provides services to predominantly low- 
income, high-risk Mexican American children aged 3 to 5. The 
goal of the program is to reduce alcohol and drug use risk fac- 
tors and enhance resiliency factors. In a full-day education/ 
treatment program, workers try to address early signs of emo- 
tional, behavioral, and learning problems, as well as monitor 



Healthy People 2000 



nority Communities 



children for signs of abuse and neglect. There is a mandatory 
parenting program for all families involved in this intervention 
program. Contact: Dr. Fred Cardenas, Mexican American 
Unity Council, Inc., 2300 West Commerce Street, Suite 300, 
San Antonio, TX 78207. Telephone: (512) 978-0503. 

The Monterey County Department of Health's Violent In- 
jury Prevention Project focuses on youth in Salinas, Cali- 
fornia. The target population is Latino and other vulnerable 
youth under 18 years of age. The project has been instrumen- 
tal in convening a broad-based Violent Injury Prevention Pro- 
gram Coordinating Council. Other efforts include a baseline 
survey to assess students' attitudes and beliefs about violence 
and the prevalence of violent actions and weapons; a successful 
ongoing media campaign; a training-tor-trainers program for 
probation officers; and a trigger-lock coupon program. For 
this intervention, local gun stores agreed to offer a 25-percent 
discount on trigger locks. Bright yellow coupon pads were 
printed and distributed at retail outlets that sell guns, as well 
as at medical offices, community health fairs, and Women, In- 
fant, and Children (\MC) nutrition program sites. In-service 
training on patient education techniques and audio-visual ma- 
terials were also provided to health professionals. Pre- and 
post-tests were developed for use in clinic settings, and 
coupons were color coded to determine point ot distribution 
and redemption patterns. Preliminary evaluation shows this to 
be an effective and easy tool to increase health professionals' 
involvement in violence prevention. Contact: Diana Jacobson, 
M.S., R.N., Monterey County Health Department, 1000 S. 
Main Street, Room 306, Salinas, CA 93906. Telephone: (408) 
755-8486. 



Migrant Workers 

In Utah, a Summer School Migrant Clinic Program is con- 
ducted by the Department of Health (Division of Family 
Health Services), in collaboration with Utah's Migrant Health 
Project, Migrant Head Start Project, and State Office of Edu- 
cation. Within this program, health screening services are 
provided to children in attendance at Migrant Head Start cen- 
ters and Migrant Education summer schools during the 
months of June and July. Written parental permission is re- 
quired for children to obtain health screening services 
through the program. Services are provided through the com- 
bined efforts of a traveling nursing team and a traveling med- 
ical examination team, which conduct clinics on-site at various 
Migrant Head Start and Migrant Education locations. Health 
screening services include physical examinations, dental 
screenings, and audiological screenings. Minor acute health 
problems identified at the time of screening are treated, if pos- 
sible. Problems requiring more extensive evaluation and/or 
follow-up are referred to health care providers or clinics 
within the respective local communities. Contact: Jan Robin- 
son, R.N., M.S., Family Health Services, 288 North, 1460 
West, P.O. Box 16650, Salt Lake City, UT 841 16-0650. Tele- 
phone: (801) 538-6140. 

The Plan de Salud del Valle Community and Migrant 
Health Center, in Fort Lupton, Colorado, established an 
oral health/dental program to provide emergency, preventive, 
and early intervention oral health services to migrant workers 



(54 percent Hispanic, 1 percent African American, and 1 per- 
cent Asian). The program responds to the peak migrant sea- 
son by expanding its hours to 10 p.m., Monday through 
Thursday. Throughout the year, provider capabilities are ex- 
panded through use of dental students from Northwestern 
University, the University of Iowa, and the University of Col- 
orado. Dental outreach in the form of preventive screening 
and referral care is provided using a mobile van. Dental hy- 
gienists from Salud are sent to migrant schools and migrant 
Head Start schools to provide prevention services and to coor- 
dinate dental services between schools and clinics. Contact: 
Dr. John McFarland, 1115 Second Street, Ft. Lupton, CO 
80621. Telephone (303) 892-0004. 

The Advanced Nurse Education Programs at Arizona 
State University and the University of San Diego are ex- 
panding existing family nurse practitioner programs to include 
a major focus on caring for migrant workers and their families. 
The nurses who graduate from these programs (1) will have 
primary care skills that will allow them to provide for about 
85-90 percent of the health care needs of migrant workers and 
their families, (2) be fluent in Spanish, and (3) have in-depth 
knowledge of the cultural and economic pressures on His- 
panic migrant workers and familiarity with their particular 
health risks, including TB, malaria, and MDS. Contacts: Dr. 
Ruth Ludemann, Advanced Nurse Education Programs at 
Arizona State University, College of Nursing, Tempe, AZ 
85287-2602; and Dr. Louise Rauckhorst, Advanced Nurse 
Education Programs at University of San Diego, School of 
Nursing, 5998 Alcala Park, San Diego, CA 92 1 10. 



Refugee and Immigrant Health 

In Illinois, the Refugee and Immigrant Health Screening 

Program manages and coordinates the activities of 1 1 local 
centers serving refugees and immigrants, providing health 
screenings and treatment, referral, and follow-up for identified 
health problems. Health conditions commonly observed at the 
centers include tuberculosis, hepatitis B, and parasitic infec- 
tions. Bilingual/bicultural staff and health education materials 
are available to assist the clients through the health screening 
process. Populations served by the program include refugees 
from Vietnam, Iraq, Bosnia, Ethiopia, and the former Soviet 
Lmion. The State Legalization Impact Assistance Grant, which 
is also administered by the Refugee and Immigrant Health 
Screening Program, provides funding to local health depart- 
ments for health services to eligible legalized aliens residing 
within dieir jurisdictions. Contact: Carolyn L. Broughton, Co- 
ordinator, Refugee and Immigrant Health Screening Program, 
Illinois Department of Public Health, 535 West Jefferson 
Street, Springfield, IL 62761. Telephone: (217) 785-431 1. 

The Indigenous Model for Enhancing Access to Genetic 
and Maternal and Child Health Services for Southeast 
Asian Refugee Populations, located at Ohio State Univer- 
sity, seeks to initiate, implement, and evaluate the effective- 
ness of an indigenous model for reducing barriers and enhanc- 
ing the utilization of genetic and other maternal and child 
health services for Southeast Asian populations. Ten objec- 
tives have been proposed, including a series of videotapes on 
selected topics in three Southeast Asian languages and a series 



Prevention '93/'94: Federal Programs and Progress 



of modules for U.S. health care providers to enhance their 
cultural competency. Contact: Moon Chen, Ph.D.. 320 West 
10th Avenue, Columbus, OH 43210-1:40. Telephone: (614) 
293-3897. 



All Minorities 

Los Angeles County, California, implemented a project ad- 
dressing intentional injuries, focusing primarily on the preven- 
tion of gang violence. The target population is African Ameri- 
can, Latino, and Asian males aged 15 to 34 who are gang 
members or who are at risk ol becoming involved in gang ac- 
tivity. Project statl have used a wide variety ol data sources in 
an attempt to describe \iolence and define what constitutes a 
violent act. The project's broad-based Violence Prevention 
Coalition has been pivotal in stimulating county-wide coordi- 
nation and cooperation. There are now more than 150 mem- 
ber agencies. The coalition's activities during the bus Angeles 
riots illustrated its spirit of cooperation in keeping the lines of 
communication open between agencies and in providing a neu- 
tral forum tor engineering a coordinated community response. 
Contact: Billie Weiss, Project Director, Injury Prevention ami 
Control Project, Los Angeles County Department of Health 
Services. 313 North I igueroa Street. Room 12". Los Angeles, 
California 90012. Telephone: (213)240-7785. 

In Florida, a street outreach staff from the Pinellas County 
Public Health I nil set up condom jars at different locations 
(e.g.. a bar. a beautv salon, a barbecue stand) in south Pinellas 
Count)'. Outreach stall have established regular tunes and lo- 
cations tor refilling these jars and have been able to provide 
I ll\ AIDS and S I'D education and risk-reduction education 
to high-risk individuals in the community. Through this out- 
reach, public awareness about AIDS prevention has been 
raised. Contact: Tori Johnston. Health Educator II. HRS 
Pinellas County Public Health Unit, 500 7th Avenue South. 

St. Petersburg, FL 33701. Telephone: (813)823-0401 ext. $38. 

The Wilson County 1 health Department in North Carolina 
sponsored a community-oriented sports and health festival 
known as Hoops for Health. "Through this project, minority 

males have the opportunity to play in a 3-on-3 basketball tour- 
nament, as well as participate in health and social education ex- 
hibits. Information was provided on gun control, smoking/to- 
bacco cessation, drinking and driving, date rape, AIDS/STDs, 
testicular cancer, and several other health behavior topics. 
Hoops for Health has been a successful program, with food 
and door prizes donated by various businesses. Contact: Linda 
Barrett, Wilson Countv Health Department, 1801 Glendaie 
Drive, Wilson, NC 27893. Telephone: (919) 291-5470. 

The Colorado Department of Health's Cancer Control Pro- 
gram has established the Colorado Women's Cancer Con- 
trol Initiative to promote adherence to routine breast and 
cervical cancer screening exams. This initiative supports the 
following activities, especially to benefit the African American 
and Hispanic women in participating communities: public ed- 
ucation and outreach; professional education and support of 
health care providers to refer clients; quality 7 assurance of 
screenings: elimination of financial barriers; tracking and fol- 
low-up activities; and evaluation and surveillance to monitor 



prevalence of morbidity and mortality of breast and cervical 
cancer. In cooperation with five community coalitions made 
up of African American and Hispanic women, this initiative 
developed DO IT FOR LIFE, a series of educational presen- 
tations about breast and cervical cancer. Contact: Carole A. 
Chrvala, Director, Cancer Control Program, 4300 Cherry 
Creek Drive South, Denver, CO 80222-1530. Telephone: 

(303)692-2524. 

The Multicultural Prenatal Drug and Alcohol Prevention 
Project ol the Women's Action Alliance aims to decrease the 
use ol both legal and illegal drugs before and during preg- 
nane)' in two underserved communities — the Pilsen-Little 
Milage in Chicago and the Crown Heights and Bedford 
Stuyvesant sections ol Brooklyn. I wo women's centers that 
have historically served a variety ol health and social needs in 
an African American and Latino community will offer a series 
of educational support groups and referral services to women 
of childbearing age and to substance-abusing pregnant 
women. Contact: Chris Kirk, 370 Lexington Avenue, Room 
603, New York, NY. Telephone: (212) 532-8330, ext. 106. 

The Overcoming Ethnocultural Barriers to Genetic Ser- 
vices Project in San Francisco, California, seeks to identify 

innovative and culturally appropriate techniques to overcome 
barriers to genetic services among diverse groups unfamiliar 
with AVestern culture and medical terminology. The project 
will identilv and address ethnocultural barriers to genetic ser- 
vices and serve as an educational and training resource for 
providers ol genetic services to multi-ethnic populations. 
Contact: Alitchell Golbus, M.D., Telephone: (415) 821-8358. 

The ( lentral Seattle ( !ommunity I lealth Center in Washing- 
ton has developed a tree community-based cardiovascular dis- 
ease prevention program called Sound Heart for Seattle's 
low-income communit) residents and African American 
churches. Health promotion/disease prevention services in- 
clude blood pressure and cholestorol screenings and worksite 
health promotion programs. The population served by the 
program is 53 percent African American, 15 percent Asian/Pa- 
cific Islander, 2 percent Hispanic American, and 1 percent 
American Indian. Contact: Bill Hobson, Central Seattle Com- 
munity Health Centers, 105 14th Avenue, Suite #2C, Seattle, 
\\ A 98122. Telephone: (206) 461-6910. 

The Newark Community Health Center in New Jersey es- 
tablished an H1\ T Program to serve high-risk populations (57 
percent African .-American, 41 percent Llispanic, and 2 percent 
multicultural) served by the center. Services include health ed- 
ucation, prevention programs, and a counseling support group 
supported by trained medical/health professionals. Contact: 
Bob Russell, Newark Community Health Center, 741 Broad- 
way North, Newark. XJ 07104. Telephone: (201) 483-1300. 

The Peer Education Programs in Rhode Island are experi- 
encing much success in conveying specific health information 
to pre-teens and teenagers. The AIDS Program provides an 8- 
week health education series to pre-teens aged 7 to 13 and an 
8-week .AIDS Program to 14- to 2 1 -year-olds. It also conducts 
Safety X T et Parries in the homes of teenagers in which an array 
of health issues are presented. The Family Life Peer Educa- 
tion Program provides an ongoing series to students aged 13 



Healthy People 2000 in Minority Communities 



to 15. The series includes workshops in abstinence, puberty, 
male and female anatomy, sexually transmitted diseases, and 
birth control methods. The Teen Peer Educators are trained 
to conduct workshops, to be conference facilitators, and to 
lead teen panel discussions and debates. Contact: Paul Lopes, 
Director, John Hope Settlement House, 7 Burgess Street, 
Providence, PJ 02903. Telephone: (401) 421-6993" 

The CARE Program in Lancaster, Pennsylvania, targets 
fourth graders at high risk for alcohol and other drug use. Stu- 
dent CARE groups, home visits with families, summer camp, 
parent groups, field trips, and family activities are all means by 
which the CARE program is reducing risk factors and increas- 
ing resiliency among children. Contact: Dr. Kirk Fisher, Co- 
ordinator of Pupil Sendees, School District of Lancaster, P.O. 
Box 150, Lancaster, PA 17608. Telephone: (717) 291-6146. 

The PACT (Policy, Action, Collaboration, and Training) 
Against Violence in California is a youth violence preven- 
tion effort conducted by Contra Costa County Health Ser- 
vices Department in a coalition effort with nine community 
agencies. Twenty-five youths aged 10 to 18 receive training in 
leadership and conflict resolution skills and participate in out- 
reach programs coordinated by the collaborating agencies. 
Community presentations, forums, and school-based pro- 
grams are other components of this multi-faceted project. 
Contact: Nancy Baer, Andres Sota, 75 Santa Barbara Road, 
Pleasant Hill, CA 94523. Telephone: (510) 646-6511. 

In Milwaukee, Wisconsin, Neighborhood Partners pro- 
vides the tools that small grassroots groups need to build 
neighborhood coalitions to fight alcohol and drug abuse and 
other specific problems in their communities. Neighborhood 
Partners is a "consulting service on wheels," offering leader- 



ship development training, research and planning technology, 
and logistical support to neighborhood block clubs, church 
groups, parent associations, and youth organizations. A net- 
work of 60 coalitions by 1996 is planned. Contact: Janis 
Wilberg, Ph.D., Social Development Commission, 231 West 
Wisconsin Avenue, Milwaukee, WI 53203. Telephone: (414) 
272-5600. 

The New York Healthy Heart Program combines a com- 
munity-based intervention program with a state-wide media 
campaign to encourage residents to adopt healthy behaviors 
that will reduce their risk of heart disease. The community- 
based interventions are located in Niagara County, Otsego- 
Schoharie Counties, Ithaca, White Plains, the Bedford- 
Stuyvesant area of Brooklyn, East Harlem, Central Harlem, 
and die Washington Heights-Inwood area of north Manhat- 
tan. Programs in Brooklyn and Harlem focus primarily on 
health promotion needs of African Americans and Hispanics. 
Contact: Sonya Hedlund, Director, State Healthy Heart Pro- 
gram. New York State Department of Health, Room 557 
Corning Tower, Empire State Plaza, Albany, NY 12237- 
0602. Telephone: (5 1 8) 474-093 1 . 



Summary 

These programs are a sampling of current efforts to address 
health disparities among racial and ethnic population groups 
in the United States. In order to successfully reach the 
Healthy People 2000 goals and objectives, health promo- 
tion and disease prevention activities must reach all Ameri- 
cans. The ultimate goal of these efforts is to empower individ- 
uals to make well-informed and positive health behavior 
choices to improve their health. 



Prevention '93/'94: Federal Programs and Progress 



© 



Chapter 



Health Status 
Trends 

HP 



his chapter examines trends in mortality rates and 
causes and selected health status factors for the 
general population as well as major age groups 
m^B^^m (infants, children, adolescents and young adults, 

adults, and older adults) and specific population groups (people with low 
income, Alaska Natives and American Indians, Asians and Pacific 
Islanders, Blacks, Hispanics, and people with disabilities) addressed in 
Healthy People 2000: National Health Promotion and Disease Prevention 
Objectives. These health status measures enhance our understanding of the 
Nation's progress in disease prevention and health promotion. 

The three broad goals of HEALTHY PEOPLE 2000 establish the struc- 
ture of this chapter. The first section focuses on healthy life: the increase 
of healthy life as a proportion of an individual's entire life span and the 
elimination, or compression, of morbidity from preventable disease and 
disability are the true aims of prevention. The emphasis on the quality of 
life, rather than simply life extension, moves away from a narrow focus 
on only the end result. 

The next section focuses on the health disparities that are so prevalent 
in the United States. The 1990 objectives documented significant dispar- 



o 



Prevention '93/'94: Federal Programs and Progress 



i the health status of population groups. Specific groups 
lag behind the general population and the white population in 
almost even' health indicator. Healthy People 2000 estab- 
lished specific population objectives for many ol the overall 
objectives in order to focus attention on these inequities and. 
therein', encourage prevention strategies to reduce them. 

The final section of this chapter addresses access to primary 
care. Healths People 2000 established universal access to 
preventive services as a goal tor the Nation. Disease preven- 
tion and health promotion cannot realistically he accepted as a 
possibility tor all Americans unless everyone has access to a 
regular source of primary care. For a substantial number ot 
Americans, however, access to care remains a serious problem. 
Socioeconomic status, rather than race or ethnicity, seems to 
he the biggest obstacle to achieving this goal under the con- 
straints of the present day health care system. Among the 
goals ofhealth care reform, as well as Hi \i ri-n Peopli 2000, 
is to address and resolve this problem. 



Overall Trends 

Following sharp declines in the l c '~0s. the age-adjusted 
death rate tor all Americans decreased more gradually 
throughout the l'^SOs to reach 520.2 in I 1 ' 1 '!), the lowest age- 
adjusted death rate in the history of the United Stales. The 
total number of deaths in 1990 was 2,148,463, a slight de- 
crease from 1989 ami the record number ol 2,167,999 deaths 
in 1988 

During the 1980s, there were significant declines in death 
rates for three ot the leading causes ot death among Ameri- 
cans: heart disease, stroke, and unintentional injuries. In 1990, 
these trends continued downward. Infant mortality also de- 
creased to 9.2 per 1,000 live births, the lowest level in the Vi 
tion's history. Improvements in these areas give hope that the 
1990s will see more progress, especially for diseases that have 
not declined significantly, such as cancer. 



'Age-adjusted death rates show what the level of mortality would he if 
there were no changes in the age composition of the population from 
year to year and are therefore better indicators than unadjusted rates 
ot changes over time in the risk ot dying. All death rates mentioned 
in this chapter are adjusted to the 1940 population unless otherwise 
specified. 



Goal 1: Increase the Span of 
Healthy Life for Americans 

The first ofthe three broad goals of Hi \i.iii\ Peopli 2000 

is to increase the span ot healthy lite lor Americans. Beyond 
the aim ol extending lite, which has lor so long guided our 
medical system, the extension ot bealthy life tits naturally into 
a prevention agenda for the Nation. Health promotion and 

disease prevention is a means toward the end ol good health 
with the absence ol unnccessarv disease anil disability. 

In the course of this century, life expectancy at birth has in- 
d In almost oil percent, from 4" years in 1900 to over 75 
years in 1990. This progress has been largely due to the ad- 
vances ot science and public health in conquering life-threat- 
ening ami communicable diseases. The evolution from com- 
municable diseases to chronic diseases ami injuries as the 
leading causes ol death and disability, coupled with the aging 
ol the population, directs our attention to quality ol lite issues. 
The end result ol disease can be measured by mortality stalls 
ties. Inn the cost in morbidity ami human suffering associated 
with both chronic and infectious disease goes tar beyond mor- 
tality statistics. Following is a review ol recent mortality 
trends, as well as data relevant to quality ol lite measures, such 
as years ol health) life as a proportion ol total lite, years ol po- 
tential life lost before age 65, and the percentage of people ex- 
periencing limitation of activity. 



Health Status Trends 



Major Causes of Death Among 
the U.S. Population 

Figure 1 shows the 10 major causes of death among the 
total U.S. population with the highest age-adjusted death rates 
in 1990 and compares death rates from these causes in 1990 
and 1980. This group may differ somewhat from the 10 "lead- 
ing" causes of death, which traditionally are derived from a 
ranking based on the number of deaths rather than the magni- 
tude of the age-adjusted rates. The top five causes of death, 
which accounted for about 71 percent of total deaths in 1990, 
are diseases of the heart (heart disease), malignant neoplasms, 
including neoplasms of lymphatic and hematopoietic tissues 
(cancer), accidents and adverse effects (unintentional injuries), 
cerebrovascular diseases (stroke), and chronic obstructive pul- 
monary diseases and allied conditions (chronic lung disease). 

From 1980 to 1990, the age-adjusted death rate from heart 
disease declined 25 percent; that for unintentional injuries, in- 



cluding motor vehicle crashes, 2 3 percent; and that tor stroke, 
32 percent. The death rate from cancer did not change sub- 
stantially over the period. The death rate for chronic lung dis- 
ease, which generally has been rising since 1950, increased 24 
percent. Diabetes mellitus (diabetes) and homicide and legal 
intervention (homicide) have shown a pattern of recent in- 
creases after reaching a plateau in the mid-1980s. The rate for 
diabetes increased 21 percent from 1985 to 1990; and that for 
homicide, 23 percent from 1985 to 1990. 

Human immunodeficiency virus (HrV infection) had the 
10th highest age-adjusted death rate in 1990, increasing 13 
percent from 1989. FHV infection has been classified sepa- 
rately for reporting only since 1987, and the total increase in 
the age-adjusted death rate between 1987 and 1990 was 78 
percent. Chronic liver disease and cirrhosis (cirrhosis) de- 
clined 30 percent between 1980 and 1990, to become the 11th 
highest age-adjusted death rate. Pneumonia/influenza has in- 
creased slightly in recent years, and suicide has shown minimal 
fluctuation in the age-adjusted death rate since 1980. 



Figure 1. Death Rates for Major Causes of Deaths, 1980 and 1990 



Heart Disease 



Cancer 



Injuries 



Stroke 



Chronic Lung Disease 



Pneumonia/Influenza 



Diabetes 



Suicide 



Homicide/Legal 
Intervention 



HIV Infection* 



i 135.0 
132.8 



197 
159 



14 
129 

11.7 
10.1 

11 5 
11 4 

102 
10.8 



1990 
1980 



9.8 
5.5 



Rate Per 100,000 (Age Adjusted) 

"Data are for 1987. the first year HIV infection was reported separately, and 1990 

Source: Centers for Disease Control and Prevention. National Center for Health Statistics. National Vital Statistics System 



© 



Prevention '93/'94: Federal Programs and Progress 



Infant Mortality 



The U.S. infant mortality rate declined to 9.2 per 1,000 live 
births in 1990, the lowest level in the Nation's history. Tech- 
nological advances in neonatal care, particularly aiding low- 
birth-weight infants, fueled the 54-percent decline in mortal- 
ity from 1970 to 1990. llRAl.nn PEOPI 1 2000 set a target of " 
deaths per 1,000 live births for the year 2000. 

Despite substantial progress in the 1980s, die United States 
still ranks below many other developed nations in interna- 
tional comparisons of infant mortality. The U.S. rate in 1989 
was higher than that of 23 other industrialized nations, includ- 
ing Japan (4.6). Canada (".1). and Sweden I ; s 

Significant reductions in the U.S. infant mortality rate will 
depend upon closing the gap between rates for whites anil mi- 
nority populations with high infant mortality rates. For exam- 
ple, the 1990 rate for blacks was 2.2 times the rate for whites, 
and rates for some Vmcrican Indian tribes and for Puerto Ri- 
cans were also considerably higher than for white infants. The 
greatest opportunities for progress in the 1990s are to he- 
found in increasing access to anil receipt of prenatal care- 
rather than in advances in neonatal medical treatment. 

Of the 4.2 million children born in 1990, 38,351 died before 



their first birthday. Four causes account for more than half of all 
infant deaths: congenital anomalies, sudden infant death syn- 
drome (SIDS), disorders relating to short gestation anil low birdi 
weight (less dian 5 pounds, 8 ounces), and respiratory distress 
syndrome (Fig. 2). Between 1989 and 1990, the rates for bodi 
congenital anomalies and short gestation/low birth weight de- 
creased by 1 percent, and SIDS decreased by 7 percent. Respira- 
tor} distress syndrome declined most dramatically, by 24 percent. 

Although ranked only third as a primary cause of infant 
death in 1990, short gestation/low birdi weight is linked widi 
approximately three-quarters o( all infant deaths in the first 
month, and 60 percent ot all infant deaths occur among low- 
birth-weight infants. Low birth weight occurred in about 7 
percent ot live births — a rate virtually unchanged since 1980. 
Low -birth-weight infants are 40 times more likelv to die in 
the fust i() days alter birth, and low-birth-weight survivors 
suiter chronic physical and learning disabilities two to three 
tunes more often than normal weight infants. 

The congenital anomalies (birth detects) most likely to re- 
sult in death include heart disease, respiratory distress syn- 
drome, malformations of the brain and spine, and combina- 
tions of several malformations. Infant mortality from 
congenital anomalies had been declining steadily, although it 
increased slightly in 1990, 



Figure 2. Leading Causes of Infant Mortality, 1990 



Congenital Anomalies 



Sudden Infant 
Death Syndrome 



Short Gestation and 
Low Birth Weight 



Respiratory Distress 
Syndrome 




Total 



Deaths Per 100,000 Live Births 
White I Black 



Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 



Health Status Trends 



Mortality Among Children 

The three leading causes of death among children declined in 
1990, continuing the steady trend that characterized die 1980s. 
The category of accidents and adverse effects (unintentional in- 
juries), including motor vehicle crashes, drowning, fires, falls, 
and poisoning, is the leading cause of death for children, as seen 
in Figure 3. About 41 percent of the 30.8 deaths per 100,000 
children aged 1 through 14 were due to unintentional injuries, 
and about half of those stemmed from motor vehicle crashes. 

The overall unintentional injury death rate in this age group 
declined 10.1 percent from 1989 to 1990, and the motor vehi- 
cle crash death rate declined 9.1 percent. Several factors are 
responsible for the recent decline in motor vehicle injuries, in- 



cluding improvements in child passenger safety laws, automo- 
bile design, safety seats, and public awareness and advocacy. 
Since 1985, all 50 States and the District of Columbia have 
had child safety seat use laws. 

The cancer death rate among children also declined 6 per- 
cent from 1989 to 1990, contrary to the trend in the total pop- 
ulation. Rates for most of the other 10 leading causes of death 
among children also declined or remained steady in 1990. 
Deaths from HIV infection were only about 1 percent of total 
deaths among children and the rate remained at 0.4 per 
100,000 in 1989 and 1990. The homicide rate among children 
held steady in 1990, after having increased 6 percent from 

1988 to 1989, with the greatest increase among those aged 5 
to 14. Benign neoplasms increased from 0.3 per 100,000 in 

1989 to 0.4 m 1990. 



Figure 3. Leading Causes of Death for Children Aged 1 Through 14, 1990 



Injuries 



Cancer 



Congenital Anomalies 



Homicide 



Heart Disease 



Pneumonia/Influenza 



Suicide 





HIV Infection 
Chronic Lung Disease 

Meningitis 

Deaths Per 100,000 Children 
Source: Centers for Disease Control and Prevention. National Center for Health Statistics. National Vital Statistics System 



Prevention ' 9 3 / ' 9 4 : Federal Programs and Progress 



Mortality Among Adolescents 
and Young Adults 

Figure 4 ranks the 10 leading causes of death tor those aged 
1 5 to 24 in 1990. A long-term decline in this age group's death 
rate has reversed in recent years, and 1990 saw a 2-percent in- 
crease over 1989. Death rates for cancer and heart disease 
changed little in 1990 compared to 1989 la decrease of 2 per- 
cent and unchanged, respectively), hut were offset in part by 
an increase tor homicide (up 21 percent) :\nd a slight increase 
in suicide (up 2 percent I. 

The percentage ol total deaths due to injuries in this age 
group in 1990 was approximately the same as in 1950 — 44 

percent. Motor vehicle crashes accounted lor 78 percent ol 
unintentional injury deaths in 1990. Motor vehicle crashes 



are the leading cause ot death ot this group's white youth, 
and over halt ot these deaths arc associated with alcohol. 
The Steadil) rising homicide rate now accounts for 2(1 per- 
cent ol' total deaths, compared to 13.5 percent in 1980. 
1 lomicide is the leading killer ot black adolescents ami black 
young adults, and the association with alcohol and other 
drugs is substantial. 

Suicide, the thud leading cause ol mortality, increased to 
13.2 percent of total deaths from 1989 to 1990. Most deaths 
from suicide are among white males, although females in this 
age group attempt suicide approximately three times more 
otten than males. Firearms are used in about 60 percent ot 
adolescent anil young adult suicides. 

Data for 1990 showed a decline in the death rate from 1 11Y 
infection from 1.6 per 100.000 in 1989 to 1.5, although it re- 
mains the sixth leading cause of death. 



Figure 4. Leading Causes off Death for Adolescents and Young Adults 
Aged 15 Through 24, 1990 



Injuries 



Homicide 



Suicide 



Cancer 



Heart Disease 



HIV Infection 






Congenital Anomalies 
Stroke 

Pneumonia/Influenza 
Chronic Lung Disease 



Deaths Per 100,000 Youth 



Source: Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System 



Health Status Trends 



Mortality Among Adults 

The 10 leading causes of death for adults aged 25 to 64 in 
1990 are ranked in Figure 5. The long-term decline in this age 
group's death rate has continued: in 1990, the rate was 406.2 
deaths per 100,000. This represents an 18-percent decline 
since 1980. The three leading causes of death — cancer, heart 
disease, and unintentional injuries — account for about 62 per- 
cent of all deaths in this age group. The fourth leading cause 
of death is HIV infection, which has risen sharply and ac- 
counted for about 4.6 percent ot deaths in this age group in 
1990. These and several other top causes oi death between the 
ages of 25 and 64 have been associated with risk factors related 
to lifestyle. 

Rates for the leading causes of death continued to decline in 
1990, with the exception of HIV infection, homicide, suicide, 
and diabetes. The death rate from HIV infection in this aee 



group increased 13.9 percent from 1989 to 1990; over 90 per- 
cent of all HIV deaths occurred in this age group. The homi- 
cide death rate also climbed, with an overall increase of 4.4 
percent. Among those aged 25 to 34, the homicide rate in- 
creased by 7 percent. Diabetes, the 10th leading cause of 
death, also rose 1.1 percent. Suicide increased 2 percent from 
1989 to 1990. 

From 1989 to 1990, the heart disease death rate declined by 
4.6 percent; about 17 percent of all heart disease deaths in the 
United States were among those aged 25 to 64. Other notable 
declines in 1990 were chronic liver disease, 5.5 percent; unin- 
tentional injuries, 3.8 percent; and chronic lung disease, 3.6 
percent. Cancer, the leading cause of death in this age group 
since 1983, also declined by about 1 percent, and stroke de- 
clined 2.7 percent. In contrast to the noticeable decline in the 
percent ot overall deaths due to injury, motor vehicle deaths 
declined only slightly, from 19 percent of total deaths in this 
age group in 1989 to 18.8 percent in 1990. 



Figure 5. Leading Causes of Death for Adults Aged 25 Through 64, 1 990 



Cancer 



Heart Disease 




Injuries 



HIV Infection 



Suicide 



Stroke 

Liver Disease 

Homicide 

Chronic Lung Disease 

Diabetes 

Deaths Per 100,000 Adults 

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 



Prevention '93/94: Federal Programs and Progress 



Life Expectancy 

The overall decline in the death rate has been mirrored by a 
steady increase in life expectancy at birth tor most Americans. 
Since 1^00. life expectancy at birth (the average number of 
years chat a group of infants is expected to live if they experi- 
ence throughout life the age-specific death rates prevailing 
during the year of their birth) has increased by 60 percent, 
from 4" years in 1900 to a record high of 75.4 years in 1990. 
From 1980 to 1990, life expectancy increased 1." years, or 2.3 
percent. Figure 6 illustrates the gradual increase in lite ex- 
pectancy since 1950. 

White females continue to have the highest lite expectancy 
at birth. 79.4 years in 1990. Lite expectancy tor white males 
and black females is '2.' and 73.6 years, respectively; black 



males continue to have the lowest life expectancy, 64.5 years. 
In the United States, males have typically had lower life ex- 
pectancies than females. The disparity in life expectancy be- 
tween the black and white populations has not narrowed sig- 
nificantly over the past 50 years and, in tact, has widened over 
the past several years. The difference in lite expectancy be- 
tween the black and white populations was 7 years in 1990, 
versus 6.3 years in 1980, 7 years in 1970, ami ".4 years in 1960. 
Life expectancy at birth for both males and females is lower 
in the Limed States than in many other developed nations. 
For example, males born m the I mud States in L>8 1 > had a 
life expectancy at birth of 71.7 years, \ersus ""6.2 years in 
Japan, "4.1 in Switzerland, and 73.7 in Canada. For females 
born in the United States in 1989, life expectancy at birth was 
i ars, versus 82.5 years in Japan, 81. 3 in Switzerland, and 
80.6 in Canada. 



Figure 6. Life Expectancy at Birth, by Sex, Selected Years, 1950-1990 




1950 1960 1970 1980 

fi Male Female I Total 

Source: Centers for Disease Control and Prevention. National Center for Health Statistics. National Vital Statistics System 



1990 



Health Status Trends 



Increase the Span of Healthy Life 

The average life expectancy for Americans born in 1990 
reached 75.4 years, and people who reached the age of 65 in 
1990 could expect to live 17.2 additional years. However, 
healthy life, and not just life expectancy, must be measured in 
order develop a consistent disease prevention and health pro- 
motion message. This first of the three overarching goals of 
HEALTHY People 2000 recognized the potential for healthy 
life to extend from birth beyond age 65 for all Americans, free 
from chronic, disabling diseases and conditions, preventable 
infections, and serious injury. Still, serious illness or injury, or 
loss of functional independence resulting from the cumulative 
effect of lesser impairments affecting an individual's ability to 
perform activities required for daily living, such as bathing, 
dressing, and eating, may diminish quality of life for older 



adults. As Figure 7 shows, approximately 1 5 percent of overall 
life expectancy are not healthy years. The unhealthy portion 
frequently occurs during the later years. 

During 1988-90, the chronic conditions most frequently 
indicated as the main cause of activity limitation were arthritis 
(18.9 percent of all people with activity limitation), impair- 
ments of the lower extremities (8.9 percent), spinal curvatures 
or back impairments (8.7 percent), high blood pressure (8.3 
percent), heart disease (7.1 percent), and intervertebral disk 
disorders (6.5 percent). For people under age 18, the most 
prevalent causes were asthma (22.9 percent), mental retarda- 
tion (19.4 percent), speech impairments (7.8 percent), and 
hearing impairments (5.1 percent). For adults aged 18 to 44, 
spinal curvatures, intervertebral disk disorders, and other back 
impairments accounted for 37.8 percent of activity limitations. 
At older ages, arthritis, high blood pressure, and heart disease 
predominated as causes of activity limitation. 



Figure 7. Years of Healthy Life as a Proportion of Life Expectancy, 1 990 




Life Expectancy 

75.4 years 

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, 
National Vital Statistics System and National Health Interview Survey 



Prevention ' 9 3 / ' 9 4 : Federal Programs and Progress 



Figure S combines the health status measures of healthy 
life and life expectancy at birth, comparing l v ' c '0 data for all 
races, whites, and blacks and preliminary data for 1 lispanics. 
The general population, whites, and Hispanics all can expect 
to live 85 percent of their lives in good health, compared to 
SI percent tor blacks. A similar gap exists in lite expectancy 
between blacks, who have the lowest lite expectancy at birth, 
and whites and Hispanics. who have similar lite expectancy. 
Data tor Hispanic lite expectancy and years of healthy life 
yield a paradox, because Hispanics do not compare as favor- 
ably to the general population on mam other key health indi- 
cators, including homicide. 111V infection, and access to 
health care. 

Differences in death rates tor leading causes of death, infant 
mortality rates, and prevalence ot chronic and disabling condi- 



tions among population groups contribute to these differences 
across groups in health status. For example, infant mortality, 
premature death from heart disease ami stroke, ami prevalence 
of diabetes are key factors in the lower life expectancy and 
fewer years of healthy life experienced by blacks. 

Comparisons from 1988-1990 for all-causes death rates for 
whites, Hispanics, and blacks in the 25-44 age group indicate 
that disparities in the span of healthy life have not been elimi- 
nated in the past decade: this rate was 16.1 percent higher 
among Hispanics than among whites and 143.6 percent higher 
among blacks as compared to whites. Socioeconomic causes 
are a major factor m this gap in health status, as povertj and 
near-poverrj appear as underlying elements ol main health 
problems that contribute to the excess mortality and higher 
prevalence ot chronic conditions experienced by these groups. 



Figure 8. Life Expectancy and Years off Healthy Life, by Race and 
Hispanic Origin, 1990 








Hispanic 
Years of Healthy Life 



Total 



Source: Centers for Disease Control and Prevention. National Center for Health Statistics, National Vital Statistics System and National 
Health Interview Survey 



c* 



Health Status Trends 



Major Causes of Death Among 
the U.S. Population 

Figure 1 shows the 10 major causes of death among the 
total U.S. population with the highest age-adjusted death rates 
in 1990 and compares death rates from these causes in 1990 
and 1980. This group may differ somewhat from the 10 "lead- 
ing" causes of death, which traditionally are derived from a 
ranking based on the number of deaths rather than the magni- 
tude of the age-adjusted rates. The top five causes of death, 
which accounted for about 71 percent of total deaths in 1990, 
are diseases of the heart (heart disease), malignant neoplasms, 
including neoplasms of lymphatic and hematopoietic tissues 
(cancer), accidents and adverse effects (unintentional injuries), 
cerebrovascular diseases (stroke), and chronic obstructive pul- 
monary diseases and allied conditions (chronic lung disease). 

From 1980 to 1990, the age-adjusted death rate from heart 
disease declined 25 percent; that for unintentional injuries, in- 



cluding motor vehicle crashes, 2 3 percent; and that for stroke, 
32 percent. The death rate from cancer did not change sub- 
stantially over the period. The death rate for chronic lung dis- 
ease, which generally has been rising since 1950, increased 24 
percent. Diabetes mellitus (diabetes) and homicide and legal 
intervention (homicide) have shown a pattern of recent in- 
creases after reaching a plateau in the mid-1980s. The rate for 
diabetes increased 21 percent from 1985 to 1990; and that for 
homicide, 23 percent from 1985 to 1990. 

Human immunodeficiency virus (HIV infection) had the 
10th highest age-adjusted death rate in 1990, increasing 13 
percent from 1989. HIV infection has been classified sepa- 
rately for reporting only since 1987, and the total increase in 
the age-adjusted death rate between 1987 and 1990 was 78 
percent. Chronic liver disease and cirrhosis (cirrhosis) de- 
clined 30 percent between 1980 and 1990, to become the 1 1th 
highest age-adjusted death rate. Pneumonia/influenza has in- 
creased slightly in recent years, and suicide has shown minimal 
fluctuation in the age-adjusted death rate since 1980. 



Figure 1. Death Rates for Major Causes of Deaths, 1980 and. 1990 



Heart Disease 



Cancer 



Injuries 



Stroke 



Chronic Lung Disease 



Pneumonia/Influenza 



Diabetes 



Suicide 



Homicide/Legal 
Intervention 



HIV Infection* 



3 135.0 
132.8 



19.7 
15.9 



14 
129 

: 11.7 
10.1 

11.5 

11 4 

10.2 
10.8 



1990 
1980 



98 
5.5 



Rate Per 100,000 (Age Adjusted) 

'Data are for 1987, the first year HIV infection was reported separately, and 1990 

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 



© 



Prevention ' 9 3 / ' 9 4 : Federal Programs and Progress 



Infant Mortality 

The U.S. infant mortality rate declined to 9.2 per 1,000 live 
births in 1990, the lowest level in the Nation's history. Tech- 
nological advances in neonatal eare. particularly aiding low- 
birth-weight infants, fueled the 54-percent decline in mortal- 
ity from 1970 to 1990. 1 ll U ll» PEOP1 I 2000 set a target of7 
deaths per 1,000 live births for the year 2000. 

Despite substantial progress in the 1980s, the L nited States 
still ranks below many other developed nations in interna- 
tional comparisons of infant mortality. The U.S. rate in 1989 
was higher than that of 23 other industrialized nations, includ- 
ingjapan (4.6). Canada (7.1), and Sweden (5.8) 

Significant reductions in the U.S. infant mortality rate will 
depend upon closing the gap between rates for whites and mi- 
nority populations with high infant mortality rates. For exam- 
ple, the 1990 rate for blacks was 2.2 tunes the rate for whites. 
and rates for some American Indian tribes and for Puerto Ri- 
cans were also considerably higher than for white infants. The 
greatest opportunities for progress in the 1990s are to be 
found in increasing access to and receipt of prenatal care 
rather than in advances in neonatal medical treatment. 

Of the 4.2 million children born in 1990, $8,351 died before 



dieir first birthday. Four causes account for more than half of all 
infant deaths: congenital anomalies, sudden infant death syn- 
drome (SEDS), disorders relating to short gestation and low birth 
weight (less than 5 pounds, 8 ounces), and respiratory distress 
syndrome (Fig. 2). Between 1989 and 1990, the rates for bodi 
congenital anomalies and short gestation/low birth weight de- 
creased by 1 percent, and S1DS decreased by 1 percent. Respira- 
tory distress syndrome declined most dramatically, by 24 percent. 

Although ranked only third as a primary cause of infant 
death in 1990, short gestation/low birth weight is linked with 
approximately three-quarters of all infant deaths in die first 
month, and 60 percent of all infant deaths occur among low- 
birth-weight infants. Low birth weight occurred in about 7 
percent of live births — a rate virtually unchanged since 1980. 
Low -birth-weight infants are 40 times more likely to die in 
the first 50 days after birth, and low-birth-weight survivors 
suffer chronic physical and learning disabilities two to three 
times more often than normal weight infants. 

The congenital anomalies (birth defects) most likely to re- 
sult in death include heart disease, respiratory distress syn- 
drome, malformations of the brain and spine, and combina- 
tions iif several malformations, Infant mortality from 
congenital anomalies had been declining steadily, although it 
increased slightly in 1990, 



Figure 2. Leading Causes of Infant Mortality, 1 990 



Congenital Anomalies 



Sudden Infant 
Death Syndrome 



Short Gestation and 
Low Birth Weight 



Respiratory Distress 
Syndrome 




Total 



Deaths Per 100,000 Live Births 
White I Black 



Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 



o 



Health Status Trends 



Mortality Among Children 

The three leading causes of death among children declined in 
1990, continuing the steady trend that characterized die 1980s. 
The category of accidents and adverse effects (unintentional in- 
juries), including motor vehicle crashes, drowning, fires, falls, 
and poisoning, is die leading cause of death for children, as seen 
in Figure 3. About 41 percent of the 30.8 deaths per 100,000 
children aged 1 through 14 were due to unintentional injuries, 
and about half of those stemmed from motor vehicle crashes. 

The overall unintentional injury death rate in this age group 
declined 10.1 percent from 1989 to 1990, and the motor vehi- 
cle crash death rate declined 9.1 percent. Several factors are 
responsible for the recent decline in motor vehicle injuries, in- 



cluding improvements in child passenger safety laws, automo- 
bile design, safety seats, and public awareness and advocacy. 
Since 1985, all 50 States and the District of Columbia have 
had child safety seat use laws. 

The cancer death rate among children also declined 6 per- 
cent from 1989 to 1990, contrary to the trend in the total pop- 
ulation. Rates for most of the other 10 leading causes of death 
among children also declined or remained steady in 1990. 
Deaths from HIV infection were only about 1 percent of total 
deaths among children and the rate remained at 0.4 per 
100,000 in 1989 and 1990. The homicide rate among children 
held steady in 1990, after having increased 6 percent from 

1988 to 1989, with the greatest increase among those aged 5 
to 14. Benign neoplasms increased from 0.3 per 100,000 in 

1989 to 0.4 in 1990. 



Figure 3. Leading Causes off Death for Children Aged 1 Through 14, 1990 



Injuries 



Cancer 



Congenital Anomalies 



Homicide 



Heart Disease 



Pneumonia/Influenza 



Suicide 



HIV Infection 



Chronic Lung Disease 



Meningitis 




0.2 



Deaths Per 100,000 Children 

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 



Prevention '93/'94: Federal Programs and Progress 



Mortality Among Adolescents 
and Young Adults 

Figure 4 ranks the 10 leading causes of death for those aged 
15 to 24 in 1990. A long-term decline in this age group's death 
rate has reversed in recent years, and l ( ' l) U saw a 2-percent in- 
crease over 1989. Death rates tor cancer and heart disease 
changed little in 1990 compared to 1989 (a decrease of 2 per- 
cent ami unchanged, respectively), hut were offset in part by 
an increase for homicide (up 21 percent) and a slight increase 
in suicide (up 2 percent). 

The percentage of total deaths due to injuries in this age 
group in 1990 was approximately the same as in 1950 — 14 
percent. .Motor vehicle crashes accounted tor "S percent of 
unintentional injun deaths in 1990. Motor vehicle crashes 



are the leading cause ot death ol (his group's white youth, 
and oxer half of these deaths are associated with alcohol. 
The steadily rising homicide rate now accounts for 20 per- 
cent of total deaths, compared to 15.5 percent in 1980. 
1 lomicide is the leading killer of black adolescents and black 
young adults, and the association with alcohol and other 
drugs is substantial. 

Suicide, the third leading cause ot mortality, increased to 
15.2 percent of total deaths from 1989 to 1990. Most deaths 

from suicide are among white males, although females in this 
age group attempt suicide approximately three limes more 
often than males. Firearms are used in about 60 percent ot 
adolescent and young adult suicides. 

Data tor 1990 showed a decline in the death rate from 1 IIV 
infection from 1.6 per 100,000 in 1989 to 1.5, although it re- 
mains the sixth leading cause ol death. 



Figure 4. Leading Causes of Death for Adolescents and Young Adults 
Aged 15 Through 24, 1990 



Injuries 



Homicide 



Suicide 



Cancer 



Heart Disease 

HIV Infection 

Congenital Anomalies 

Stroke 

Pneumonia/Influenza 
Chronic Lung Disease 



Deaths Per 100,000 Youth 



Source: Centers for Disease Control and Prevention. National Center for Health Statistics, National Vital Statistics System 



o 



Health Status Trends 



Mortality Among Adults 

The 10 leading causes of death for adults aged 25 to 64 in 
1990 are ranked in Figure 5. The long-term decline in this age 
group's death rate has continued: in 1990, the rate was 406.2 
deaths per 100,000. This represents an 18-percent decline 
since 1980. The three leading causes ot death — cancer, heart 
disease, and unintentional injuries — account for about 62 per- 
cent of all deaths in this age group. The fourth leading cause 
of death is HIV infection, which has risen sharply and ac- 
counted for about 4.6 percent of deaths in this age group in 
1990. These and several other top causes of death between the 
ages of 25 and 64 have been associated with risk factors related 
to lifestyle. 

Rates for the leading causes of death continued to decline in 
1990, with the exception of HIV infection, homicide, suicide, 
and diabetes. The death rate from HIV infection in this age 



group increased 13.9 percent from 1989 to 1990; over 90 per- 
cent of all HIV deaths occurred in this age group. The homi- 
cide death rate also climbed, with an overall increase of 4.4 
percent. Among those aged 25 to 34, the homicide rate in- 
creased by 7 percent. Diabetes, the 10th leading cause of 
death, also rose 1.1 percent. Suicide increased 2 percent from 
1989 to 1990. 

From 1989 to 1990, the heart disease death rate declined by 
4.6 percent; about 17 percent of all heart disease deaths in the 
United States were among those aged 25 to 64. Other notable 
declines in 1990 were chronic liver disease, 5.5 percent; unin- 
tentional injuries, 3.8 percent; and chronic lung disease, 3.6 
percent. Cancer, the leading cause of death in this age group 
since 1983, also declined by about 1 percent, and stroke de- 
clined 2.7 percent. In contrast to the noticeable decline in the 
percent of overall deaths due to injury, motor vehicle deaths 
declined only slightly, from 19 percent of total deaths in this 
age group in 1989 to 18.8 percent in 1990. 



Figure 5. Leading Causes of Death for Adults Aged 25 Through 64, 1990 



Cancer 



Heart Disease 



Injuries 



HIV Infection 



Suicide 



Stroke 



Liver Disease 



Homicide 



Chronic Lung Disease 



Diabetes 




9.5 



Deaths Per 100,000 Adults 

Source: Centers for Disease Control and Prevention. National Center for Health Statistics, National Vital Statistics System 



Q 



Prevention '93/'94: Federal Programs and Progress 



Life Expectancy 

The overall decline in the death rate has been mirrored by a 
steady increase in life expectancy at birth for most Americans. 
Since 1900, life expectancy at birth (the average number of 
years that a "roup of infants is expected to live if they experi- 
ence throughout life the age-specific death rates prevailing 
during the year of their birth) has increased by dO percent, 
from 4" years in 1900 to a record high of 75.4 years in 1990. 
From 1980 to 1990, life expectancy increased 1." years, or 2.3 
percent. Figure 6 illustrates the gradual increase in life ex- 
pectancy since 1 950. 

White females continue to ha\e the highest lite expectancy 
at birth. 79.4 years in 1990. Life expectancy for white males 
and black females is "2." and 73.6 years, respectively; black 



males continue to have the lowest life expectancy, 64.5 years. 
In the United States, males have rypicalh had lower life ex- 
pectancies than females. The disparity in life expectanq be- 
tween the black and white populations has not narrowed sig- 
nificantly Over the past 30 years and. in fact, has widened over 
the past several years. The difference in lite expectancy be- 
tween the black and white populations was " vears in 1990, 
versus 6.3 years in 1980, 7 years in 1970, ami ".4 years in 1960. 
Life expectancy at birdi for both males and females is lower 
in the United States than in many other developed nations. 
For example, males born in the L nited Stales in 1989 hail a 
life expectancy at birth of "1." years, versus "6.2 years in 
Japan, "4.1 in Switzerland, and 73.7 in Canada. For females 
born in the United States in 1989, life expectancy at birth was 
~S.s vears, versus S2.5 years in Japan, 81.3 in Switzerland, and 
SO. 6 in Canada. 



Figure 6. Life Expectancy at Birth, by Sex, Selected Years, 1950-1990 




1950 1960 1970 1980 

I Male Female I Total 

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 



1990 



Health Status Trends 



Increase the Span of Healthy Life 

The average life expectancy for Americans born in 1990 
reached 75.4 years, and people who reached the age of 65 in 
1990 could expect to live 17.2 additional years. However, 
healthy life, and not just life expectancy, must be measured in 
order develop a consistent disease prevention and health pro- 
motion message. This first of the three overarching goals of 
Healthy People 2000 recognized the potential for healthy 
life to extend from birth beyond age 65 for all Americans, free 
from chronic, disabling diseases and conditions, preventable 
infections, and serious injury. Still, serious illness or injury, or 
loss ol functional independence resulting from the cumulative 
effect of lesser impairments affecting an individual's ability to 
perform activities required tor daily living, such as bathing, 
dressing, and eating, may diminish quality of life for older 



adults. As Figure 7 shows, approximately 1 5 percent of overall 
life expectancy are not healthy years. The unhealthy portion 
frequently occurs during the later years. 

During 1988-90, the chronic conditions most frequently 
indicated as the main cause of activity limitation were arthritis 
(18.9 percent of all people with activity limitation), impair- 
ments of the lower extremities (8.9 percent), spinal curvatures 
or back impairments (8.7 percent), high blood pressure (8.3 
percent), heart disease (7.1 percent), and intervertebral disk 
disorders (6.5 percent). For people under age 18, the most 
prevalent causes were asthma (22.9 percent), mental retarda- 
tion (19.4 percent), speech impairments (7.8 percent), and 
hearing impairments (5.1 percent). For adults aged 18 to 44, 
spinal curvatures, intervertebral disk disorders, and other back 
impairments accounted for 37.8 percent of activity limitations. 
At older ages, arthritis, high blood pressure, and heart disease 
predominated as causes of activity limitation. 



Figure 7. Years of Healthy Life as a Proportion of Life Expectancy, 1990 




Life Expectancy 

75.4 years 

Source: Centers for Disease Control and Prevention. National Center for Health Statistics, 
National Vital Statistics System and National Health Interview Survey 



Prevention '93/94: Federal Programs and Progress 



Figure S combines the health status measures of healthy 
life and life expectancy at birth, comparing 1990 data for all 

races, whites, and blacks and preliminary data tor Hispanics. 
The general population, whites, and Hispanics all can expect 
to live 85 percent of their lives in good health, compared to 
SI percent for blacks. A similar gap exists in lite expectancy 
between blacks, who have the lowest lite expectancy at birth, 
and whites and Hispanics, who have similar lite expectancy. 
Data tor Hispanic lite expectancy and years of healthy life 
yield a paradox, because Hispanics do not compare as favor- 
ably to the general population on many other key health indi- 
cators, including homicide, HIV infection, and access to 
health care. 

Differences in death rates tor leading causes of death, infant 
mortality rates, and prevalence of chronic and disabling condi- 



tions among population groups contribute to these differences 
across groups in health status. For example, infant mortality, 
premature death from heart disease and stroke, and prevalence 
of diabetes are key factors in the lower life expectancy and 
fewer years of healthy life experienced b\ blacks. 

Comparisons from 1988-1990 for all-causes death rates for 
whites. 1 lispanics. and blacks in the 25-44 age group indicate 
that disparities in the span of healthy life have not been elimi- 
nated in the past decade: this rate was 16.1 percent higher 
among 1 lispanics than among whites and 145.6 percent higher 
among blacks as compared to whites. Socioeconomic causes 
are a major factor m this gap in health status, as poverty and 
near-poverty appear as underlying elements of many health 
problems that contribute to the excess mortality and higher 
prevalence of chronic conditions experienced by these groups. 



Figure 8. Life Expectancy and Years off Healthy Life, by Race and 
Hispanic Origin, 1990 



IB 


> 






White 



Black 



Life Expectancy 



Hispanic 
Years of Healthy Life 



Total 



Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System and National 
Health Interview Survey 



fffo 



Health Status Trends 



Figure 9 measures years of potential life lost (YPLL) before 
age 65 due to premature death from disease and injury. Since 
1970, the rate of years of potential life lost before age 65 for all 
races declined bv 35 percent. This general decline has been 
mirrored among whites, but not among blacks. While the se- 
lected years shown in Figure 9 indicate a downward trend, al- 
beit slow, among blacks, YPLL has increased in recent years 
among black males and females. The rate of YPLL for black 
males is consistently higher than for white males; in 1990, the 
rate was 2.2 times higher than for white males. The same can 
be said for the female rates of YPLL, with the YPLL rate for 
black females being 2.2 times as high as for white females. 

Comparisons by race and sex for the three leading causes of 
death in 1990 show consistently higher YPLL rates for blacks 
than whites. For heart disease, black males suffered 64 percent 



higher YPLL than white males; and black females, 153 per- 
cent higher than for white females. For stroke, the YPLL rate 
for black males was 3 times as high; and for black females, al- 
most 3 times as high. For cancer, the differences were smaller: 
34 percent higher for black males and 17 percent higher for 
black females. 

Other significant differences exist in YPLL by blacks com- 
pared to whites from homicide, HTV, and unintentional in- 
juries. The 1990 YPLL rate among black males from homicide 
was over 8 times that of white males; for black females, the rate 
was over 5 times higher than for white females. For fHV, the 
rate for black males was almost 3 times as high; and for black 
females, almost 10 times as high. For accidents, the rate for 
black males was 27 percent higher; for black females, the rate 
was 24 percent higher. (See Goal 2. Reduce Health Disparities.) 



Figure 9. Years off Potential Life Lost (YPLL) Before Age 65, 
by Race and Sex, Selected Years, 1970-1990 




Total 
Population 



Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 



o 



Prevention '93/94: Federal Programs and Progress 



Limitation of major life activities such as self-care, recre- 
ation, school, and work due to chronic conditions and disabili- 
ties is a significant factor in determining years of healthy lite. 
The prevalence of limitation of major activity (crude rates) 
among those at low income levels is twice that of the general 
population (Fig. 10). Low socioeconomic status and disability 
may influence each other because the existence of a major dis- 
ability often leads to lower income. Age is another major fac- 
tor in disability; in 1991, among those aged 65 and older, 57.9 
percent experienced some limitation ami 10.6 percent experi- 
enced complete limitation in major activity. 

In 1991, 1 3.5 percent (age adjusted) of all Americans suf- 
fered physical or mental impairments that limited their activi- 
ties in some manner, compared to 13.3 percent in 1986. This 
overall limitation in ability was not reflected in the category of' 
people with functional limitations so severe that they could 
not perform major activities such as working, attending 
school, or maintaining a household, where prevalence in- 
creased from 3.7 percent in 1986 to 4 percent in 1991. 



The proportion of people with family income less than 
Si 4.000 who experienced limitation of activity in 199] was _'4 
percent, up from 23 percent in 1986; the largest portion of 
this increase was among those experiencing complete limita- 
tion of major activity. Among those with family income 
greater than $50,000, prevalence of limitation declined during 
the same period, from 9.6 to 9 percent. 

In addition to the 4 percent of the total population who 
were unable to perforin a major activity (e.g., play, school, 
work, or self-care) in 1991, about 5.2 percent experienced 
some limitation in performing major activities and over 4 per- 
cent were limited in nonmajor activities. Estimates of the 
number of people with chronic, significant disabilities produc- 
ing limitation of activity vary from 34 million to 43 million. 
Many more people, of course, have impairments that are not 
yet. but could become, disabling; still more have chronic con- 
ditions, such as hypertension or alcoholism, that can lead to 
impairment and disability. Many people have several disabling 
conditions. 



y& 



Figure 10. Percentage off People Experiencing Limitation of Major Activity Caused 
by Chronic Conditions, Total and Low-Income Populations, 1983-1991 



20.0 



17.5 



15.0 



_ 12.5 
n 

o 

« 

BE 
o 

"2 10.0 



7.5 



5.0 



2.5 



0.0 




Low Income 



Total Population 



1983 1984 1985 1986 1987 1988 1989 1990 

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey 



1991 



Health Status Trends 



Activity limitations are most common among the poor, 
those who are less educated, and older people. In 1991, people 
in families with incomes of less than $14,000 a year were al- 
most twice as likely as the total population to experience limi- 
tation of activity because of their health (Fig. 11), and 2.5 
times as likely to be unable to carry on major life activities. Ac- 
tivity limitations were 4 times as common among people with 
8 years or less of education than among those with 16 years or 
more. Among Americans aged 45-64, 22.2 percent experi- 
enced some limitation of activity (Fig. 12), versus 13.5 percent 



of the total population. Among those aged 65 and older, 37.9 
percent experienced some limitation. 

The data presented above indicate that the prevalence of 
disability increases with age, resulting in a greater need for as- 
sistance in activities of daily living among older adults. About 
22 percent of people aged 65 and older were limited in one or 
more major activities in 1991, and nearly half of those aged 85 
and older needed assistance in activities of daily living. People 
aged 65 and older experienced an average of 8.8 restricted ac- 
tivity days per year, versus 7.4 days for the total population. 



a 

3 

o 
O 

0) 

< 





Figure 1 1 . Percentage of People Experiencing Limitation of Activity 
Caused by Chronic Conditions, by Family Income Level, 1991 



All Persons 
Less Than $14,000 
$14,000-24,999 
$25,000-34,999 
$35,000-49,999 
$50,000 or More 



Percent (Age Adjusted) 

Source: Centers for Disease Control and Prevention. National Center for Health Statistics. National Health Interview Survey 



Figure 1 2. Percentage of People Experiencing Limitation of Activity 
Caused by Chronic Conditions, by Age, 1991 



Under 5 



5-14 



15-44 



45-64 



65-74 




75 and over 



Percent 

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey 



f^ 



Prevention '93/'94: Federal Programs and Progress 



Goal 2. Reduce Health Disparities 

Achieving a healthier America depends upon significant im- 
provements in the health of population groups that now are at 
the highest risk of premature death, disease, and disability. Al- 
though health statistics that take race and ethnicity into ac- 
count are limited, the existing data leave no doubt that dispar- 
ities exist. A future challenge is tor data to link factors such as 
socioeconomic status, educational attainment, race, gender, 
age, and health st.uus SO that prevention strategies can lie most 
effective. 

Special attention is needed to close the gaps thai exist be- 
tween the general population and specific population groups. 
Whether the issue is chronic diseases, infectious diseases, un- 
intentional injuries, or violence-related injuries, the services 
ami protection that might effectively bring about improve- 
ments in their circumstances must he made available. The 
greatest opportunities tor improvement in, and the greatest 
threats to. the future health status of the Nation reside in pop- 
ulation groups that historical!)' have been disadvantaged eco- 
nomically, educationally, -md politically. A particularly sensi- 
tive and compelling measure of disparity is infant mortality. 
Although America's infant mortality rate is at an all-time lou. 
a persistent racial gap remains, black infants continue to die at 
more than twice the rate of white infants, and the gap has in- 
creased in recent years. 

Statistics on years of' health) life also reflect differences 
among racial and ethnic groups m the United States. Simi- 
larly, rates of disability, measured in terms of limitation of ac- 
tivity, confirm the inequities in health status. The pattern of' 
disparity in life expectancy ami years of healthy lite continues 
in mortality from major causes. Members of minorities, indi- 
viduals with low income, and other specific populations suffer 
higher rates of mortality from certain causes than the total 
population. 

Blacks made up 11." percent of the U.S. population in 1990, 
thereby constituting the Nation's largest minority group. 
Members of this group live in all regions of the country and 
are represented in every socioeconomic group. However, a 
third of all black people live in poverty, a rate almost i times 
that of the overall population. Over half live in central cities, 
in areas often typified by poverty, poor schools, crowded 
housing, high unemployment, exposure to a pervasive drug 
culture and street violence, ami generally high levels of stress. 

Life expectancy for black people has lagged behind that of 
the total population throughout this century. Since the mid- 
. the gap has widened, with the life expectancy for the 
overall population rising to "5.4 years in 1990 while black life 
expectancy stood at 69.1 years tatter reaching a high of 69.5 in 
1984). Lite expectancy is only one statistic among many others 
defining gaps that contribute to general health status: blacks 
face higher heart disease death rates, higher stroke death rates. 
higher homicide rates, higher MTV death rates, and higher in- 
fant mortality rates. Comparisons of death rates among whites 
and blacks in 1990 for the leading causes of death reveal con- 
■ and significant disparities. In fact, the age-adjusted 
lity rates for blacks are higher than whites for 13 of the 
ling causes of deaths. 

The Hispanic American population — Mexican Americans, 
Puerto Ricans, Cuban Americans, Central and South Ameri- 
can immigrants, and other immigrants of Latin American cul- 



ture or origin — is the second largest minority group in the 
United States. In 1990, 1 tispanic Americans constituted about 
9 percent ot the total population. Between 1980 and 1990, the 
1 lispanic population increased 53 percent, making this the 
second tasiest growing minority group. (Asians/Pacific Is- 
landers increased 95 percent.) 

The Hispanic population presents a sci ol health issues 
more varied because ol its composition. Heart disease and 
cancer were the causes ot highest mortality lor both llispanics 
and the overall population, but caused a smaller share ol total 
deaths among I lispanics. Some ol the widest differences in 
health status between Hispanics and non-Hispanic whiles 
were seen in greater I lispanic death rates for homicide, cir- 
rhosis. 1 11V. and diabetes, ["here are also differences in health 
status among the 1 lispanic subgroups. For example, within the 
I lispanic population, Chilians have higher cancer rates. Mexi- 
cans have higher death rates lor cirrhosis, and Puerto Ricans 
have higher rales lor stroke. 

1 he diversity that characterizes the Nation's third largest 
minority group, the more than 7 million \sian and Pacific Is- 
lander Americans, is striking. While health outcomes ol those 
born within the United States and established here for genera- 
tions are virtualK indistinguishable from the general popula- 
tion, the health ol others, pann.ul.irlv recent immigrants, is 
extremely poor. Consequently, within this minority popula- 
tion, the overall health indicators often do not show the whole 
picture. The relatively small size ol this minority group and 
the lack ol data on subgroups within it, including persons ol 
Chinese, Japanese, Filipino, Korean, Samoan, Vietnamese, 
Thai. Cambodian, Laotian, Hawaiian, and other Pacific Island 
origin, also make assessment ot leading causes ol death, dis- 
ease, and disability difficult. 

Existing data do show certain differences in risk among 
Asians .inA Pacific Islanders. 1 lean disease and cancer were 
the leading causes of death lor Wans and Pacific Islanders in 
1990, as was the case lor the general population. Infectious 
diseases such as hepatitis B and tuberculosis, however, also 
have very high incidence rates among this population, particu- 
imong recent Southeast Asian immigrants. Other causes 
ot death that have seen increases among many parts ol the 
population — homicide, suicide, and II1Y infection — remained 
lower among Wans and Pacific [slanders. 

Descendants ol the original residents ol North America, 
American Indians and Alaska Natives, compose the smallest of 
the defined minority groups. Diversity characterizes this 
group, too: it encompasses over 400 federally recognized na- 
tions, each with its own traditions and cultural heritage. Eski- 
mos. Aleuts, and Indians residing in Alaska are referred to as 
Alaska Natives; those residing in other Stales are referred to as 
American Indians. The Federal Government collects detailed 
data annually on American Indians and Alaska Natives in 33 
Si. lies lh.it include reservations. 

In general, the American Indian and Alaska Native popula- 
tion is youthful. The median age of those living in the reserva- 
tion States is about 23, compared to over 32 for the general 
population. Income and educational levels tend to be low. 
with more than 30 percent living below the poverty level and 
only 9.3 percent having college degrees. One reason for the 
youthfulness of the population is the large proportion who die 
before the age of 45. Comparison of death rates in 1990 for 
American Indians and Alaska Natives with national rates for 
whites reveals substantial disparities. xVIost excess deaths can 



Health Status Trends 



be traced to six causes: unintentional injuries, cirrhosis, homi- 
cide, suicide, pneumonia, and diabetes. Cirrhosis contributes 
significantly to death and disability in this population group; 
among American Indians, the 1990 rate was 2.5 times the rate 
for whites. Diabetes was another chronic disease dispropor- 
tionately affecting American Indians, with a 1990 rate 1.5 
times the rate for whites. The pneumonia death rate was also 
13 percent higher than among whites. 

The next section compares rates for leading health indica- 
tors among whites and other racial and ethnic groups, shed- 
ding light on the differing health profiles. 



Life Expectancy at Birth, 
by Race, 1950-1990 

Figure 13 displays the life expectancies for selected years 
from 1950 through 1990 by race, to the extent data allow. All 
life expectancies have increased considerably since 1950, but 



disparities persist for the black population. The increase in life 
expectancy since 1950 for the total population has been 10.1 
percent since 1950; for whites, 10.5 percent; and for blacks, 
13.8 percent. Although the overall disparity between blacks 
and other population groups has decreased during the last four 
decades, between 1980 and 1990 the gap actually widened. 
The difference in life expectancy between blacks and whites 
was 6.3 years in 1990, versus 5.6 years in 1980, 6.8 years in 
1970, 6.5 years in 1960, and 7.5 years in 1950. 

The 1990 Hispanic life expectancy (preliminary data) was 
79. 1 years, which compared very favorably with the rest of the 
population. Life expectancy data for Hispanics generally re- 
flect the mortality experience of Mexican Americans, the 
largest sub-group. More extensive data on different Hispanic- 
subgroups is required to evaluate accurately their varied health 
profiles: for example, Puerto Ricans appear to have worse 
health status and higher mortality than non-Hispanic whites. 
In addition, Mexican Americans born in the United States ap- 
pear to have worse health status than Mexican immigrants. 



Figure 1 3. Life Expectancy at Birth, by Race, Selected Years, 1 950-1 990 



Hispanic 



n 

4) 

> 
u 
c 
n 



a 
x 
in 

4) 

*^ 

'3 




1950 



1960 



1970 



1980 



1 990 



Source: Centers for Disease Control and Prevention, National Center lor Health Statistics, National Vital Statistics System 



ffi fe 



Prevention '93/'94: Federal Programs and Progress 



Infant Mortality Rates, by Race 
and Hispanic Origin, 1983-1987 

Perhaps the most compelling measure of disparity is infant 
mortality: although America's infant mortality rate reached an 
all-time low of 9.2 per 1,000 live births in 1990, there re- 
mained persistent gaps among populations. Poor pregnancy 
outcomes, including prematurity, low birth weight, birth de- 
lects, and infant death, are linked to low income, low educa- 
tional level, low occupational status, and other indicators of 
social and economic disadvantage. Despite this link, race often 
must serve as a proxy measure for economic status in vital sta- 
tistics data collection and analysis. 

Significant reductions in the U.S. infant mortality rate 
(LMR) will depend upon closing the gap between LMRs foi 
whites and minority populations. For example, the LMR for 
blacks was IS in 1990, or 2.4 times that of whiles, and LMRs 
lor some American Indian tribes and lor Puerto Ricans were 
also considerably higher than for white infants. Data offering 
the most reliable comparison of LMRs for a broad range ol 
racial groups are those from the National Linked files ol Live 
Births and Infant Deaths for the 1983 1987 birth cohorts 
(Fig. 14 1. These data show general improvement in the major 
population groups — whites, blacks. American Indians and 



Alaska Natives, Asians and Pacific Islanders, and Hispanics — 
but little change in relative disparity. 

In 1983, the ratio of the white LMR to that of American Indi- 
ans and Alaska Natives was 1 to 1.6. Comparable reductions in 
LMRs lor both groups b\ 1987 left the relative gap almost un- 
changed. The relative gap between whites and blacks actually 
increased slightlv from 1983 to 1987, and in 1990 it was higher 
still at 1 to 2.4. Among I [ispanics, Puerto Ricans had the high- 
est LMR in 1986— 1.4 times that of whites. B\ 1987, the Puerto 
Ric.in LMR had declined to only 1.2 times the white LMR. The 
overall l.\IR among Asians and Pacific Islanders has generally 
been equal to or below that of whites, although low numbers of 
total births .lUcui the comparability of data over time. 



Data Table for Figure 14 


Total 


1983 


1984 


198;> 


1986 


198/ 


10.9% 


10.4% 


10.4% 


10.1% 


9.8% 


American Indian 


15 2 


134 


13.1 


13.9 


13.0 


Asian/Pacific 












Islander 


8.3 


8.9 


7.8 


7.8 


7.3 


Black 


19.2 


18.2 


18.6 


18.2 


17.8 


Hispanic 


9.5 


9.3 


8.8 


8.4 


8.2 


White 


9.3 


8.9 


8.9 


8.5 


8.2 



Figure 14. Infant Mortality Rates, by Race and Hispanic Origin 
off Mother, 1983-1987 



Black 




Total 




Asian/Pacific Islander 



7.3 (A) 



933 



1984 



1985 



1986 



1987 



Source: Centers for Disease Control and Prevention. National Center for Health Siatistics. National Linked Files of Live Births and Infant Deaths 



© 



Health Status Trends 



Heart Disease 

The heart disease death rate has fallen 25 percent since 
1980 and 40 percent since 1970. In 1990, however, heart dis- 
ease was still the leading cause of death, accounting for 
720,058 deaths among Americans. It also cost Americans al- 
most 1.4 million years of potential life lost in 1990 and over 
$40 billion in direct and indirect costs. 

Many factors combine to determine whether a person will 
develop coronary heart disease and also how rapidly athero- 
sclerosis progresses. Genetic predisposition, gender, and ad- 
vancing age are recognized factors over which individuals have 
no control. Kev modifiable risk factors include cigarette 
smoking, high blood cholesterol, high blood pressure, exces- 
sive body weight, and long-term physical inactivity. Control 
of each of these modifiable risk factors is important in the pre- 
vention of coronary heart disease. People with diabetes, who 
are especially prone to vascular disease, may also benefit by 
controlling these factors. Risk reduction in those who already 
suffer from coronary heart disease and are at risk of having an- 
other coronary event is also of great importance. 



Cigarette smokers are at increased risk for fatal and nonfatal 
heart attacks and for sudden death. Smokers have a 70-percent 
greater coronary heart disease rate, a twofold to fourfold 
greater incidence of coronary heart disease, and a twofold to 
fourfold greater risk for sudden death than nonsmokers. 

Elevated blood cholesterol levels are associated with a 
higher incidence of coronary heart disease, and reducing both 
the mean serum cholesterol level and the proportion of people 
with high blood cholesterol can have an important impact on 
morbidity and mortality rates for coronary heart disease. Each 
1 -percent reduction in serum cholesterol level has been asso- 
ciated with 2 -percent reduction in heart disease death. 

Overweight is a risk factor for high blood pressure, high 
blood cholesterol, diabetes, and coronary heart disease. Physi- 
cal inactivity affects multiple risk factors and also increases the 
risk of coronary heart disease. 

HEALTHY People 2000 set as an objective a 26-percent reduc- 
tion in heart disease deaths — to no more than 100 per 100,000 
people — by the year 2000. A specific population target was also 
set for blacks at 115 per 100,000, a 29-percent reduction. Figure 
15 shows the 1990 death rates for coronary heart disease for the 
general population as well as for specific population groups. 



Figure 15. Death Rates for Coronary Heart Disease, by Race 
and Hispanic Origin, 1990 



Objective 15.1 

Reduce coronary heart disease deaths to no more than 100 per 100,000 people. 



4) 

01 

5. 
s 
© 
© 

o 





Total American Indian/ Asian/ 

Alaska Native Pacific 

Islander 



Black 



Hispanic 



White 



Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 



Prevention ' 9 3 ; ' 9 4 : Federal Programs and Progress 



Coronary heart disease death rates are higher among men 
than among women and are higher among blacks than among 
the rest of the population. In 1990, the death rate due to coro- 
nary heart disease was more than 30 percent higher for blacks 
than the overall population rate ami was almost 55 percent 
higher than tor whites, the next highest specific population 
rate. Hispanics, Asians and Pacific Islanders, and American In- 
dians and Alaska Natives all had lower death rates lor coro- 
nan heart disease compared to the overall rate. 

Note: The chart and objective tor coronary heart disease 
discussed in this section use different International Classification 
of Diseases, Ninth Revision (ICD-9) codes than the mortality 
rates discussed earlier. See "Cause-of-death Terminology — 
Codes." Health, United States, 1992 and Healthy People 2000 
. page 241. 



Cancer 



Cancer accounts lor almost one oi every' tour deaths in the 
United States. In 1990, 505,322 Americans died of cancer. 



making it the second leading cause of death overall. Cancer 
cost the United States approximately S 104 billion in 1°°0 in 
direct and indirect costs, as well as 1.9 million years of poten- 
tial life lost. In 1993, almost 1,170,000 new cancer cases were 
expected, not including carcinoma in situ and basal and squa- 
mous cell skin cancers. The incidence of these skin cancers, 
approximately 90 percent of which are preventable, is esti- 
mated to be over 700,000 eases annually. 

The potential tor reducing cancer incidence and mortality 
through primary prevention and early detection strategies is 
large. More than 30 percent ol cancer deaths are due to ciga- 
rette smoking, a cause that could he eliminated through preven- 
tion and control efforts. Early detection and intervention can 
significantly reduce cancer mortality tor some cancers. Accord- 
ingly, Hi \t Tm Peopli Join) set objectives for cancer diat 
focus on those areas ol cancer prevention and detection with the 
greatest potential for reducing cancer incidence, morbidity, and 
mortality. The targets include reduction of tobacco use, dietary 
change, and improvements in early detection. 

I u inv If' shows the 1990 death rates due to cancer of the 
general population and for specific population groups. 



Figure 16. Death Rates for Cancer, by Race and 
Hispanic Origin, 1990 



Objective 16.1 

Reverse the rise of cancer deaths to achieve 
a rate of no more than 130 per 100.000 people 



■a 
n 

s 

B 

o 
o 
o 
6 

a 




Total 



American Indian/ 
Alaska Native 



Asian/ 

Pacific 

Islander 



Black 



Hispanic 



White 



Source: Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System 



ealth Status Trends 



Figure 9 measures years of potential life lost (YPLL) before 
age 65 due to premature death from disease and injury. Since 
1970, the rate of years of potential life lost before age 65 for all 
races declined by 35 percent. This general decline has been 
mirrored among whites, but not among blacks. While die se- 
lected years shown in Figure 9 indicate a downward trend, al- 
beit slow, among blacks, YPLL has increased in recent years 
among black males and females. The rate of YPLL for black 
males is consistently higher than for white males; in 1990, the 
rate was 2.2 times higher than for white males. The same can 
be said for the female rates of YPLL, with the YPLL rate for 
black females being 2.2 times as high as for white females. 

Comparisons by race and sex for the three leading causes of 
death in 1990 show consistently higher YPLL rates for blacks 
than whites. For heart disease, black males suffered 64 percent 



higher YPLL than white males; and black females, 153 per- 
cent higher than for white females. For stroke, the YPLL rate 
for black males was 3 times as high; and for black females, al- 
most 3 times as high. For cancer, the differences were smaller: 
34 percent higher for black males and 17 percent higher for 
black females. 

Other significant differences exist in YPLL by blacks com- 
pared to whites from homicide, FHV, and unintentional in- 
juries. The 1990 YPLL rate among black males from homicide 
was over 8 times that of white males; for black females, the rate 
was over 5 times higher than for white females. For HIV, the 
rate for black males was almost 3 times as high; and for black 
females, almost 10 times as high. For accidents, the rate for 
black males was 27 percent higher; for black females, the rate 
was 24 percent higher. (See Goal 2. Reduce Health Disparities.) 



Figure 9. Years off Potential Life Lost (YPLL) Before Age 65, 
by Race and Sex, Selected Years, 1970-1990 



20.284 




Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 



o 



Prevention ' 9 3 ' ' 9 4 : Federal Programs and Progress 



Limitation oi major life activities such as self-care, recre- 
ation, school, and work due to chronic conditions and disabili- 
nificant factor in determining years of healthy life. 
The prevalence of limitation of major activity (crude rates) 
among those at low income levels is twice that of the general 
population (Fig. 10). Low socioeconomic starus and disability 
may influence each other because the existence ol a major dis- 
ability often leads to lower income. Age is another major fac- 
tor in disability; in 1991, among those aged 65 anil older. 57.9 
percent experienced some limitation and 10.6 percent experi- 
enced complete limitation in major activity. 

In 1991, 13.5 percent (age adjusted) of all Americans suf- 
fered physical or mental impairments that limited their activi- 
ties in some manner, compared to 13.3 percent in 1986. Ibis 
overall limitation in ability was not reflected in the category ol 
people with functional limitations so severe that they could 
not perform major activities such as working, attending 
school, or maintaining a household, where prevalence in- 
creased from 5.7 percent in 1986 to 4 percent in 1991. 



The proportion of people with family income less than 
$14,000 who experienced limitation of activity in 1991 was _'4 
percent, up from 23 percent in 1986; the largest portion of 
this increase was among those experiencing complete limita- 
tion of major activity. Vmong those with family income 
greater than 550.000, prevalence of limitation declined during 
the same period, from 9.6 to l > percent. 

In addition to the 4 percent of the total population who 
were unable to perform a major activity (e.g., play, school, 
work, or self-care) in 1991, about 5.2 percent experienced 
some limitation in performing major activities and over 4 per- 
cent were limited in nonmajor activities. Estimates of the 
number ot people with chronic, significant disabilities produc- 
ing limitation ol activit) vary from 34 million to 43 million. 
Many more people, ot course, have impairments that are not 
yet, but could become, disabling; still more have chronic con- 
ditions, such as hypertension or alcoholism, that can lead to 
impairment and disability. Many people have several disabling 
conditions. 



^a 



Figure 10. Percentage off People Experiencing Limitation of Major Activity Caused 
by Chronic Conditions, Total and Low-Income Populations, 1983-1991 



20.0 



17.5 



15.0 



_ 12.5 



a 
a 
a 
•? 10.0 



c 



« 7.5 

a 

a. 



5.0 



2.5 



0.0 




Low Income 






Total Population 




1983 1984 1985 1986 1987 1988 1989 1990 

Source: Centers for Disease Control and Prevention. National Center for Health Statistics, National Health Interview Survey 



1991 



Health Status Trends 



Activity limitations are most common among the poor, 
those who are less educated, and older people. In 1991, people 
in families with incomes of less than $14,000 a year were al- 
most twice as likely as the total population to experience limi- 
tation of activity because of their health (Fig. 11), and 2.5 
times as likely to be unable to carry on major life activities. Ac- 
tivity limitations were 4 times as common among people with 
8 years or less of education than among those with 16 years or 
more. Among Americans aged 45-64, 22.2 percent experi- 
enced some limitation of activity (Fig. 12), versus 13.5 percent 



of the total population. Among those aged 65 and older, 37.9 
percent experienced some limitation. 

The data presented above indicate that the prevalence of 
disability increases with age, resulting in a greater need for as- 
sistance in activities of daily living among older adults. About 
22 percent of people aged 65 and older were limited in one or 
more major activities in 1991, and nearly half of those aged 85 
and older needed assistance in activities of daily living. People 
aged 65 and older experienced an average of 8.8 restricted ac- 
tivity days per year, versus 7.4 days for the total population. 



a 

3 

o 

o 

< 




Figure 1 1 . Percentage of People Experiencing Limitation of Activity 
Caused by Chronic Conditions, by Family Income Level, 1991 



All Persons 
Less Than $14,000 
$14,000-24,999 
$25,000-34,999 
$35,000-49,999 
$50,000 or More 



Percent (Age Adjusted) 

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey 



Figure 12. Percentage of People Experiencing Limitation of Activity 
Caused by Chronic Conditions, by Age, 1991 



Under 5 



5-14 



15-44 



45-64 



65-74 




75 and over 



Percent 

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey 



^ffr 



Prevention '93/'94: Federal Programs and Progress 



Goal 2. Reduce Health Disparities 

Achieving a healthier America depends upon significant im- 
provements in the health of population groups chat now arc at 
the highest risk ol premature death, disease, and disability . \\- 

though health statistics that take race and ethnicitv into ac- 
count arc limited, the existing data leave no doubt thai dispar- 
ities exist. V future challenge is tor data to link factors Mich as 
socioeconomic status, educational attainment, race, gender, 
.me. and health status so that prevention strategies can he most 
e freed 

Special attention is needed to close the gaps that exist be- 
tween the genera! population anil specific population groups. 
Whether the issue is chronic diseases, infectious diseases, un- 
intentional injuries, or violence-related injuries, the services 
and protection that might effectiveh bring about improve- 
ments in their circumstances must he made available. The 
greatest opportunities for improvement in. and the greatest 
threats to. the future health status of the Nation reside in pop- 
ulation groups that historically have been disadvantaged eco- 
nomically, educationally, -mA politically. A particularly sensi- 
tive and compelling measure of disparity is infant mortality. 
Although America's infant mortality rate is at an all-time low. 
.1 persistent racial gap remains. Black infants continue to die at 
more than twice the rate of white infants, and the gap has in- 
creased in recent years. 

Statistics on years of healthy life also reflect differences 
among racial and ethnic groups in the United States. Simi- 
larly, rates of disability, measured in terms of limitation of ac- 
tivity, confirm the inequities in health si.mis The pattern ol 
disparity in lite expectancy and years ol healthy lite continues 
in mortality from major causes. Members of minorities, indi- 
viduals with low income, and other specific populations suffer 
higher rates ol mortality from certain causes than the total 
population. 

Blacks made up 1 1." percent of the U.S. population in 1990, 
therein constituting the Nation's largest minority group. 
Members ol this group live in all regions o( the country and 
are represented in every socioeconomic group. However, a 
third of all black people live in poverty, a rate almost 5 times 
that of the overall population. Over half live in central cities, 
m areas often typified by poverty, poor schools, crowded 
housing, high unemployment, exposure to a pervasive drug 
culture and street violence, and generally high levels ol Stress. 

lite expectancy tor black people has lagged behind that of 
the total population throughout this century. Since the mid- 
1980s, the gap has widened, with the life expectancy for the 
overall population rising to "5.4 years in 1990 while black life 
expectancy stood at 69.1 years (after reaching a high of 69.5 in 
Life expectancy is only one statistic among many others 
defining gaps that contribute to general health status: blacks 
face higher heart disease death rates, higher stroke death rates. 
higher homicide rates, higher HIV death rates, and higher in- 
fant mortality rates. Comparisons of death rates among whites 
and blacks in 1990 for the leading causes of death reveal con- 
t and significant disparities. In fact, the age-adjusted 
mortality rates for blacks are higher than whites for 13 of the 
ling causes of deaths. 

The Hispanic American population — Mexican Americans, 
uban Americans. Central and South Ameri- 
can immigrants, and other immigrants of Latin American cul- 



ture or origin is the second largest minority group in the 
United States. In 1990, 1 lispanic Americans constituted about 
9 percent of the total population. Between l'^SO and 1990, the 
Hispanic population increased 53 percent, making this the 
second fastest growing minority group. (Asians. Pacific Is- 
landers increased c >5 percent.) 

The Hispanic population presents a set ol health issues 
more varied because ol its composition. Heart disease and 
cancer were the causes ol highest mortality for both 1 lispanics 
.^nA the overall population, but caused a smaller share of total 
deaths among Hispanics. Some ol the widest differences in 
health status between Hispanics and non-Hispanic whiles 
were seen in greater 1 lispanic death rates tor homicide, cir- 
rhosis. 1 11Y. and diabetes. There are also differences in health 
status among the 1 lispanic subgroups, for example, within the 
1 lispanic population. Cubans have higher cancer rates. Mexi- 
cans have higher death rates tor cirrhosis, and Puerto Ricans 
have higher rates for stroke. 

The diversity that characterizes the Nation's third largest 
minority group, the more than 7 million Asian ami Pacific Is- 
lander Americans, is striking. While health outcomes of those 
horn within the United Slates and established here tor genera- 
tions are virtually indistinguishable from the general popula- 
tion, the health of others, particularly recent immigrants, is 
extremelv poor. Consequently, within this minority popula- 
tion, the overall health indicators often do not show the whole 
picture. The relatively small size of this minority group and 
the lack of data on subgroups within it. including persons ol 
Chinese. Japanese. Filipino, Korean, Samoan, Vietnamese, 
Thai, Cambodian, Laotian. I lawaiian, and other Pacific Island 
origin, also make assessment ol leading causes ol death, dis- 
ease, .tnd disability difficult. 

Existing data do show certain differences in risk among 
\sians and Pacific Islanders. Heart disease and cancer were 
the leading causes of death lor Asians and Pacific Islanders in 
1990, as was the case for the general population. Infectious 
diseases such as hepatitis B and tuberculosis, however, also 
have very high incidence rates among this population, particu- 
larly among recent Southeast \sian immigrants. Other causes 
of death that have seen increases among many parts ol the 
population — homicide, suicide, and I 11V infection — remained 
lower among Asians and Pacific Islanders. 

Descendants of the original residents of North America, 
American Indians and Alaska Natives, compose the smallest of 
the defined minority groups. Diversity characterizes this 
group, too: it encompasses over 400 federally recognized na- 
tions, each with its own traditions and cultural heritage. Eski- 
mos, Aleuts, ami Indians residing in Alaska are referred to as 
Alaska Natives; those residing in other States are referred to as 
American Indians. The Federal Government collects detailed 
data annually on American Indians and Alaska Natives in 33 
States that include reservations. 

In general, the American Indian and Alaska Native popula- 
tion is youthful. The median age of those living in the reserva- 
tion States is about 23, compared to over 32 for the general 
population. Income and educational levels tend to be low, 
with more than 30 percent living below the poverty level and 
only 9.3 percent having college degrees. One reason for the 
vouthfulness of the population is the large proportion who die 
before the age of 45. Comparison of death rates in 1990 for 
.American Indians and Alaska Natives with national rates for 
whites reveals substantial disparities. Most excess deaths can 



Health Status Trends 



be traced to six causes: unintentional injuries, cirrhosis, homi- 
cide, suicide, pneumonia, and diabetes. Cirrhosis contributes 
significantly to death and disability in this population group; 
among American Indians, the 1990 rate was 2.5 times the rate 
for whites. Diabetes was another chronic disease dispropor- 
tionately affecting American Indians, with a 1990 rate 1.5 
times the rate for whites. The pneumonia death rate was also 
1 3 percent higher than among whites. 

The next section compares rates for leading health indica- 
tors among whites and other racial and ethnic groups, shed- 
ding light on the differing health profiles. 



Life Expectancy at Birth, 
by Race, 1950-1990 

Figure 13 displays the life expectancies for selected years 
from 1950 through 1990 by race, to the extent data allow. All 
life expectancies have increased considerably since 1950, but 



disparities persist for the black population. The increase in life 
expectancy since 1950 for the total population has been 10.1 
percent since 1950; for whites, 10.5 percent; and for blacks, 
13.8 percent. Although the overall disparity between blacks 
and other population groups has decreased during the last four 
decades, between 1980 and 1990 the gap actually widened. 
The difference in life expectancy between blacks and whites 
was 6.3 years in 1990, versus 5.6 years in 1980, 6.8 years in 
1970, 6.5 years in I960, and 7.5 years in 1950. 

The 1990 Hispanic life expectancy (preliminary data) was 
79.1 years, which compared very favorably with the rest of the 
population. Life expectancy data for Hispanics generally re- 
flect the mortality experience of Mexican Americans, the 
largest sub-group. More extensive data on different Hispanic 
subgroups is required to evaluate accurately their varied health 
profiles: for example, Puerto Ricans appear to have worse 
health status and higher mortality than non-Hispanic whites. 
In addition, Mexican Americans born in the United States ap- 
pear to have worse health status than Mexican immigrants. 



Figure 13. Life Expectancy at Birth, by Race, Selected Years, 1950-1990 



Hispanic 



is 

> 

> 
o 

c 

IB 



a 
x 




1950 



1960 



1970 



1980 



1990 



Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 



© 



Prevention '93/'94: Federal Programs and Progress 



Infant Mortality Rates, by Race 
and Hispanic Origin, 1983-1987 

Perhaps the most compelling incisure of disparity is infant 
mortality: although America's infant mortality rate reached an 
all-time low of 9.2 per 1,000 live births in 1990, there re- 
mained persistent yaps among populations. Poor pregnancy 
outcomes, including prematurity, low birth weight, birth de- 
tects, and infant death, are linked to low income, low educa- 
tional level, lo« occupational status, and other indicators ol 
social and economic disadvantage. Despite this link, race often 
must serve as a prow measure tor economic status in vital sta- 
tistics data collection and analysis. 

Significant reductions in the U.S. infant mortality rate 
(LMR) will depend upon closing the gap between LMRs for 
whites and minority populations. For example, the LMR for 
blacks was IS in 1 ( ' ( '(). or 2.4 times that of whites, and LMRs 
foi some American Indian trihes and tor Puerto Ricans were 
also considerably higher than tor white infants. Data offering 
the most reliable comparison ol LMRs ;d range ol 

racial groups are those from the National Linked Files ot Live 
Hirths and Infant Deaths for the 1983-1987 birth cohorts 
(Fig. 14i. These data show general improvement in the major 
population groups— whites, blacks, American Indians and 



Alaska Natives. Asians and Pacific Islanders, and Hispanics — 
but little change in ivl.it iv e disparity. 

In 1983, the ratio of the white L\1R to that of American Indi- 
ans .]nd \laska Natives was 1 to 1.6. Comparable reductions in 
LMRs tor both groups 1>\ 1987 left the relative gap almost un- 
changed. The relative gap between whites and blacks actually 
increased slightly from 1983 to l''S~. and in 1 ( ' { '() it was higher 
still at 1 to 2.4. Among 1 lispanics, Puerto Ricans hail the high- 
est 1MR m 1 1 >S6 — 1.4 times that of whites. By 1987, the Puerto 
Rican LMR had declined to only 1.2 times the white LMR. The 
overall 1MR among \sians and Pacific Islanders has generally 
been equal to or below that ol whiles, although low numbers of 
total births affect the comparability ot data over time. 



Data Table for Figure 14 


Total 


1983 


1984 


1985 


1986 


1987 


10.9°o 


10.4% 


10.4% 


10.1% 


9.8% 


American Indian 


15.2 


134 


131 


13.9 


13.0 


Asian Pacific 












Islander 


8.3 


8.9 


7.8 


7.8 


7.3 


Black 


19.2 


18.2 


18.6 


18.2 


17.8 


Hispanic 


9.5 


9.3 


8.8 


8.4 


8.2 


White 


9.3 


8.9 


8.9 


8.5 


8.2 



Figure 14. Infant Mortality Rates, by Race and Hispanic Origin 
of Mother, 1983-1987 



Black 



American Indian/Alaska Native 



Total 



Hispanic 




8.3 (A) 



Asian/Pacific Islander 



7.3 (A) 



1983 



1984 



1985 



1986 



1987 



Source: Centers for Disease Control and Prevention. National Center for Health Statistics. National Linked Files of Live Births and Infant Deaths 



Health Status Trends 



Heart Disease 

The heart disease death rate has fallen 25 percent since 
1980 and 40 percent since 1970. In 1990, however, heart dis- 
ease was still the leading cause of death, accounting for 
720,058 deaths among Americans. It also cost Americans al- 
most 1.4 million vears of potential life lost in 1990 and over 
$40 billion in direct and indirect costs. 

Many factors combine to determine whether a person will 
develop coronary heart disease and also how rapidly athero- 
sclerosis progresses. Genetic predisposition, gender, and ad- 
vancing age are recognized factors over which individuals have 
no control. Key modifiable risk factors include cigarette 
smoking, high blood cholesterol, high blood pressure, exces- 
sive body weight, and long-term physical inactivity. Control 
of each of these modifiable risk factors is important in the pre- 
vention of coronary heart disease. People with diabetes, who 
are especially prone to vascular disease, may also benefit by 
controlling these factors. Risk reduction in those who already 
suffer from coronary heart disease and are at risk of having an- 
other coronary event is also of great importance. 



Cigarette smokers are at increased risk for fatal and nonfatal 
heart attacks and for sudden death. Smokers have a 70-percent 
greater coronary heart disease rate, a twofold to fourfold 
greater incidence of coronary heart disease, and a twofold to 
fourfold greater risk for sudden death than nonsmokers. 

Elevated blood cholesterol levels are associated with a 
higher incidence of coronary heart disease, and reducing both 
the mean serum cholesterol level and the proportion of people 
with high blood cholesterol can have an important impact on 
morbidity and mortality rates for coronary heart disease. Each 
1 -percent reduction in serum cholesterol level has been asso- 
ciated with 2-percent reduction in heart disease death. 

Overweight is a risk factor for high blood pressure, high 
blood cholesterol, diabetes, and coronary heart disease. Physi- 
cal inactivity affects multiple risk factors and also increases the 
risk of coronary heart disease. 

HEALTHY PEOPLE 2000 set as an objective a 26-percent reduc- 
tion in heart disease deaths — to no more than 100 per 100,000 
people — by the year 2000. A specific population target was also 
set for blacks at 115 per 100,000, a 29-percent reduction. Figure 
15 shows the 1990 deadi rates for coronary heart disease for the 
general population as well as for specific population groups. 



Figure 1 5. Death Rates for Coronary Heart Disease, by Race 
and Hispanic Origin, 1990 



Objective 15.1 

Reduce coronary heart disease deaths to no more than 1 00 per 1 00,000 people. 



■o 
n 
i 

5. 
o 
o 
o 
o" 
o 




Total American Indian/ Asian/ 

Alaska Native Pacific 

Islander 



Black 



Hispanic 



White 



Source: Centers for Disease Control and Prevention. National Center for Health Statistics. National Vital Statistics System 



o 



Prevention '93/94: Federal Programs and Progress 



Coronary heart disease death rates are higher among men 
than among women and are higher among blacks than among 
the rest of the population. In 1990, die death rate due to coro- 
nary heart disease was more than SO percent higher tor blacks 
than the overall population rate and was almost 35 percent 
higher than for whites, the next highest specific population 
rate. Hispanics, Asians anil Pacific Islanders, and American In- 
dians and Alaska Natives all had lower death rates for coro- 
nary heart disease compared to the overall rate. 

Note: The chart and objective for coronary heart disease 

discussed in this section use different International Classification 

of Diseases, Xintk Revision (ICD-9) codes than the mortality 

rates discussed earlier. See "Cause-ot-dcath Terminology — 

.." Health, United States, 1992 and Healthy People 2000 

. . page 241. 



Cancer 



Cancer accounts tor almost one of every tour deaths in the 
United States. In 1990, 505,322 Americans died of cancer. 



making it the second leading cause ot death overall. Cancer 
cost the United States approximately $104 billion in 1990 in 
direct and indirect costs, as well as 1.9 million years of poten- 
tial life lost. In 1993, almost 1,170,000 new cancer cases were 
expected, not including carcinoma in situ and basal and squa- 
mous cell skin cancers. The incidence of these skin cancers, 
approximately 1 '0 percent oi which are preventable, is esti- 
mated to be over 700,000 cases annually. 

1 he potential for reducing cancer incidence and mortality 
through primary prevention and early detection strategies is 
large. More than 30 percent of cancer deaths are due to ciga- 
rette smoking, a cause that could be eliminated through preven- 
tion and control efforts. Earl) detection and intervention can 
significantly reduce cancer mortality for some cancers. Accord- 
ingly, 111 alii iv PEOPLE 2000 set objectives for cancer that 
locus on those areas of cancer prevention and detection with die 
greatest potential tor reducing cancer incidence, morbidity, and 
mortality. The targets include reduction of tobacco use. dietary 
change, and improvements in early detection. 

Figure 16 shows the 1990 death rates due to cancer of the 
general population and lor specific population groups. 



Figure 16. Death Rates for Cancer, by Race and 
Hispanic Origin, 1990 



Objective 16.1 

Reverse the rise of cancer deaths to achieve 
a rate of no more than 130 per 100.000 people 



■a 
X 

i 
a 

_5 

o 
o 
o 

6 

o 




Total American Indian/ Asian/ 

Alaska Native Pacific 

Islander 



Black 



Hispanic 



White 



Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 



Health Status Trends 



Among blacks, the cancer death rate was 35 percent higher 
than that for the general population. The overall cancer death 
rate for Asians and Pacific Islanders was significantly below 
the rate for the general population, although specific sub- 
groups experienced higher incidence rates than the general 
population for certain cancers: Hawaiians and breast cancer, 
Southeast Asian men and lung cancer, and Southeast Asians 
and liver cancer. 



Stroke 

Cerebrovascular disease was the third leading cause of death 
in the United States in 1990, causing 144,088 deaths. Stroke is 
also a major cause of morbidity, as 400,000 to 500,000 Ameri- 
cans suffer non-fatal strokes each year. Stroke mortality has 
declined by almost 60 percent since 1970, and this decline is 
primarily attributed to the improved control of high blood 
pressure. Evidence also suggests that cigarette smoking is a 



risk factor for stroke and that smoking cessation reduces 
stroke risk. 

The Healthy People 2000 objective is to reduce stroke 
deaths to no more than 20 per 100,000 people. The stroke 
death rate for the general population was 27.7 per 100,000 
people for 1990. Of the three leading causes of death, the 
stroke death rate showed the greatest disparity between blacks 
and the rest of the population: the death rate from stroke is 75 
percent greater for blacks. To help narrow this gap, a specific 
population target proposing a greater proportional reduction 
has been set for blacks at 27 per 100,000. 

Rates were lower for whites, Asians and Pacific Islanders, 
American Indians and Alaska Natives, and Hispanics than they 
were for blacks. For Hispanics, however, health status for dif- 
ferent subgroups varied. While Mexican Americans have low 
rates of cerebrovascular disease, stroke rates among New York 
Puerto Ricans are high. Figure 17 shows the death rates for 
stroke for die general population as well as for specific popula- 
tions in 1990. 



Figure 1 7. Death Rates for Stroke, by Race and 
Hispanic Origin, 1990 



Objective 15.2 

Reduce stroke deaths to no more than 
20 per 100,000 people. 



■D 

n 

i 

2. 

o 
o 
o 
o 

o 




Total 



American Indian/ 
Alaska Native 



Asian/ 
Pacific 
Islander 



Black 



Hispanic 



White 



Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 



© 



Prevention '93/'94: Federal Programs and Progress 



Unintentional Injuries 

Unintentional injuries were the fourth leading cause ol 
death in 1990, killing 91,983 individuals. During the first four 
decades ot life, unintentional injuries claim more lives and 
more years ol potential life than infectious or chronic disease 
in 1990, 2.1 million years ol potential life were lost to unin- 
tentional injuries. 

Motor vehicle crashes account for approximately halt of the 
deaths from unintentional injuries; tails rank second, followed 
by poisoning, drowning, and residential tires. Millions more 
people are incapacitated b) unintentional injuries, with many 
suffering lifelong disabilities. Direct and indirect costs due to 
unintentional injuries in the United States are approximate!) 
Si 50 billion each year. 

Any significant reduction in the number ol injuries will re- 
quire the combined eltorts ol many fields, including health, 
education, transportation, law, engineering, architecture, and 
safety sciences. Efforts to reduce death and disability from un- 
intentional injuries must also be combined with efforts to re- 



duce alcohol and other drug abuse, a leading factor in motor 
vehicle crashes. 

Although the death rates for unintentional injuries appear 
uniform in comparison to other health indicators, notable 
disparities do exist. Unintentional injur) death rates among 
American Indians and Uaska Natives in the 1 14. 15-24, and 
25 — H age groups ranged from two to three limes higher 
than those tor the general population. \n estimated 75 per- 
cent ot unintentional injun' deaths in this population are al- 
cohol-related. The death rale lor blacks due to unintentional 
injun is 22 percent higher than among the general popula- 
tion, w hile I lispanics are onl) slightly higher than the overall 
rate. 

The HEALTHS PEOPl I 2000 objective is to reduce deaths 
caused b) unintentional injuries to no more than 29.3 per 
100. (Kill people. There are also three sub-objectives l"i 
American Indians \l.iska Natives, the target is 66.1; lor black 
males, the target is 51.9; and tor white males, the target is 
42.'>. Figures 18 shows the 1990 death rales due to uninten- 
tional injuries lor the general population as well as lor specific 
population groups. 



Figure 18. Death Rates for Unintentional Injuries, by Race 
and Hispanic Origin, 1890 



Objective 9.1 

Reduce deaths caused by unintentional injuries to no more than 
29.3 per 100.000 people. 



■c 
c 

(A 

a 

- 
i> 
a 
S. 

o 
o 
o 
o" 

c 




Total 



Source: Centers for Disease Control and Prevention. National Center for Health Statistics, National Vital Statistics System 



White 



tFT% 



Health Status Trends 



Suicide 

Suicide is the eighth leading cause of death in the United 
States and a serious potential outcome of mental illness and 
mental disorders. In 1990, 30,906 people died of suicide. 
Mental disorders such as schizophrenia, panic disorder, and 
adjustment and stress reactions, as well as alcohol and other 
drug abuse, have been implicated in both attempted and com- 
pleted suicides. 

Injuries resulting from gunshots cause a majority of suicide 
deaths, and much of the increase in the suicide rate since the 
1950s can be accounted for by firearm-related deaths. Most 
attempted suicides, however, are associated with poisoning (by 
pill ingestion) and laceration. Judging the effectiveness of in- 
terventions designed to prevent mental illness and promote 
mental health in reducing intentional suicide deaths requires 
consideration of the many confounding effects. These include 



differential availability, accessibility, and acceptability of lethal 
weapons, as well as community variations in gun ownership 
and laws controlling the sale and purchase of handguns. 

Suicide rates vary substantially by gender, age, and 
race/ethnicity. For instance, men are more likely to commit 
suicide, with rates higher for whites and American Indians and 
Alaska Natives. Since the 1950s, there has also been a steady 
increase in suicide among all youth aged 15-19. The 1990 sui- 
cide rate for the 15-24 age group is nearly three times the 
1950 rate. The Healthy People 2000 objective is to reduce 
the overall suicide rate to no more than 10.5 per 100,000 peo- 
ple. The 1990 rate for the overall population was 11.5 per 
100,000 people, and this rate has been increasing, not decreas- 
ing. Figure 19 shows the 1990 suicide rates by race and His- 
panic origin. The white and the American Indian and Alaska 
Native populations both have rates surpassing that of the gen- 
eral population, due in large part to the high rates for young 
adult males in both populations. 



Figure 19. Death Rates for Suicide, by Race and Hispanic Origin, 1990 



Objective 6.2 

Reduce suicides to no more than 1 0.5 per 1 00,000 people. 



3 

m 

A 

■2. 
o 

o 
o 
o 

o 



a 

a 

re 
m 




Total 



American 

Indian/Alaska 

Native 



Asian/ 
Pacific 

islander 



Black 



Hispanic 



White 



Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 



Q 



Prevention '93/'94: Federal Programs and Progress 



Homicide 

In 1990, homicide and legal intervention was the ninth 
leading cause of death, claiming 24,932 people. Men, 
teenagers, and young .ulnlts. particularly Macks and i [ispanics, 
are most likely to be murder victims. Most homicides are 
committed with a firearm, occur during an argument, and 
occur among people who are acquainted with one another. 

Homicide is one of the Nation's most challenging public 
health problems, and the inequity with which it strikes the 
Nation's population groups is telling. No cause of death so 
greatly differentiates Black Americans from other groups as 
homicide. While blacks constitute only 11.7 percent ol the 
population, they accounted tor almost halt ol the homicide 
deaths in the United States in 1990. 

Disparities in homicide rates between blacks and whites 
were among the greatest. The 1990 rate among black males 
was 7.7 tunes that ol white males; among black females, it was 
4/> times that o( white females. The Hispanic population also 
experienced a significantly higher death rate from homicide. 
The overall I lispanic rate lor 1990 was over 2.<< times that ot 



the white population. Among 1 [ispanics aged 1 5 to 44, the dis- 
I'.uitv was even greater, with over three times as many His- 
panics dying as a result of homicide. 

Poverty has been identified as an extremely important risk fac- 
tor in homicide. Ibis is a critical variable to consider, because if 
the high incidence of homicide among blacks and other minority 
groups simply reflects greater poverty, then preventive interven- 
tions should be targeted toward all persons living in povcrtv . 

Vnother important factor associated with homicide is the 
use. manufacture, and distribution of drugs. Violence mav 
occur as a consequence ot the pharmacological effects of 
drugs, economically motivated crimes to support drug use. or 
interactions related to the manufacture, buying, and selling of 
drugs. No national data allow tor a determination ol the pro- 
portion ot homicides associated with drug use in these three 
ways; however, studies conducted m Miami and New i ork 
City indicate that at least 25 percent of the homicides occur- 
ring in these cities mav be associated with drug use. 

l'he 111 \i n-n People 2000 objective is to reduce homi- 
cides to no more than ".J per 1(10. OIK) people. The 1990 
homicide rates lor the general population and by race and 
Hispanic origin are shown in figure 20. The distinctive lea- 



Figure 20. Death Rates for Homicide, by Race and Hispanic Origin, 1990 



Objective 7.1 

Reduce homicides to no more than 7.2 per 100.000 people. 



■o 
? 
i 

B 

O 

o 
o 
o' 
o 




Total American Asian/ 

Indian/Alaska Pacific 

Native Islander 



Black Hispanic White 



Source: Centers (or Disease Control and Prevention. National Center (or Health Statistics. National Vital Statistics System 



£f% 



Health Status Trends 



tures are the high rates for the black and Hispanic popula- 
tions, and the comparatively low rates for the white and Asian 
and Pacific Islander populations. The rate for the overall pop- 
ulation is 10.1 homicides per 100,000 people. 

Note: The chart and objective for homicide discussed in this 
section use different International Classification of Diseases, Ninth 
Revision (ICD-9) codes than the mortality rates discussed ear- 
lier. See "Cause-of-death Terminology — Codes," Health, 
United States, 1992 and Healthy People 200(1 Review, page 241 . 



HIV Infection 

In 1990, 25,188 Americans died as a result of HIV infection, 
making it the 10th leading cause of death. The cumulative 
total of deaths due to HIV in the United States through 1990 
was approximately 113,000 people, and the total number of 
.AIDS cases through 1990 was over 182,000. By the end of 
1993, an estimated total of 390,000 to 480,000 cases of AIDS 
will have been diagnosed in the United States and 285,000 to 



340,000 people will have died from the disease. (These projec- 
tions were based on the case definition used prior to the latest 
revision in January 1993; the final totals may be higher.) 

HIV and AIDS are a growing threat to the health of the 
Nation and will continue to make major demands on health 
and social service systems for many years. The annual cost of 
AIDS was estimated to be $5 billion to $13 billion in 1992. 
Because there is no known cure for AIDS, the first priority is 
to stop the spread of the HIV infection. 

New prevention and control strategies must be adopted na- 
tionwide. Many of the HIV-infected people in the United 
States are unaware that they have the virus. Educational ef- 
forts and testing are imperative to help infected people adopt 
behaviors that prevent them from infecting others, to prevent 
or reduce adverse psychological reactions, to help uninfected 
individuals maintain behaviors that reduce their risk of infec- 
tion, to help spouses and sexual partners of infected people 
adopt infection-preventing behaviors, and to provide HIV-in- 
fected people with early medical intervention that can prolong 
life. 



Figure 21. Death Rates for HIV Infection, by Race, 
Hispanic Origin, and Age, 1 988-1 990 



28.7 




16 3 15.9 



9.3 




Total American Asian/ 

Indian/ Pacific Islander 

Alaska Native 



Black 



Hispanic 



White 



25-44 45-64 

'Based on fewer than 20 deaths 

Source: Centers for Disease Control and Prevention. National Center for Health Statistics. National Vital Statistics System 



ittl 



Prevention '93/'94: Federal Programs and Progress 



The populations most affected by HIV Jitter markedly 
by region, and the resources available to treat and prevent 
111V van according to population. Data from the AIDS 
Surveillance System show that racial and ethnic popula- 
tions, especially blacks ami Hispanics, have Keen dispro- 
portionately affected by HIV. In 1990, 30 percent of 
deaths dtie to the HIY infection occurred among blacks, 
who made up only 1 1." percent ot the population; 1" per- 
cent occurred among Hispanics, who made up onl) '' pel 
cent ot the population. Among individuals between the 
ages of J ^ anil 44. which was the most vulnerable age 
group with respect to 111V, the black HIV death rate v\.is 
over 2~ times that ot the general population, ami the His- 
panic death rate due to HIV was 1.9 times that of the gen- 
eral population. In 1992, blacks and Hispanics constituted 
34 percent and IS percent of AIDS cases, respectively, and 
their AIDS case rates were 2.9 and 1.6 times that of the 
general population. Asians and Pacific Islanders repre- 
sented fewer than seven-tenths of 1 percent of deaths from 
HIV infection in 1990, far below their percentage of the 
population, and the American Indian and Alaska Native 
population constituted only 0.15 percent of HIV deaths. 
Figure .1 I p. 33) shows the 1988-1990 rates of death due 
to 111V infection for the overall population as well as for 
specific population groups. 



Goal 3. Achieve Access to Care 

The third 111 VI lll\ PEOPI I 2000 goal is to achieve access 
to preventive services for all Americans. Access to care can 
contribute to greater life expectancy and extended years ol 
healthy life. As the data in preceding sections demonstrate, de- 
clines in death rates and improvements in other important 
measures of the Nation's health have been widespread; how- 
ever, the relative gap between the health status of most Amer- 
icans and certain minority and low in( i ime groups has actually 
widened in the past decade. Access to preventive sen ices is de- 
pendent upon adequate insurance coverage ami availability of 
a source of primary care that is geographically accessible and 
otters culturallj appropriate services, including counseling on 
healthy lifestyle. 

Data on the disparity in health insurance coverage confirm 
the significance ot socioeconomic factors in determining ac- 
cess to primary care. In 1989, 15.7 percent of all people under 
age 65 had no health insurance by private or public tonus <.i 
coverage (Fig. 22). up from \2.^ percent in 1980. Income level 
was a significant factor in lack ol coverage: among those living 
in families with incomes below $14,000 per year, 57.3 per- 
cent — nearly 2': times the overall rale — lacked coverage in 
\lmost 54 million Americans live in families with an in- 



Figure 22. Health Insurance Coverage for People Aged 64 and Younger, 

by Type of Coverage, 1989 




Private Insurance 

I All 

Low Income 



Medicaid 

Under 15 Years 
Black 



Not Covered 



White 



Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey 

Note: Percentages do not add to 100 because the percentage with other types of health insurance (e.g.. military. Medicare) is not shown 



Health Status Trends 



come below the Federal poverty level, including nearly 13 
million children. 

As income level increased, so did health insurance coverage; 
among those with family incomes from $14,000-$24,999 p er 
year, 21.4 percent lacked coverage in 1989. Only 9.3 percent 
of those in the $25,000-534,999 income range lacked cover- 
age. Among those whose income level was above $50,000, just 
3.2 percent had no coverage. Education level and employment 
status were also important factors in health insurance cover- 
age. Among those aged 18-64, 30.1 percent of people with less 
than a high school education lacked coverage, as did 39.2 per- 
cent of people who were unemployed. The relative gap be- 
tween the health status of whites and that of blacks and other 
minorities was reflected in insurance coverage: only 14.5 per- 
cent of whites lacked coverage, versus 22 percent of blacks and 
up to 20 percent of other minorities. 

Children generallv had higher coverage rates than adults in 
all income and racial groups, although disparities were still ev- 
ident. In 1989, 14.9 percent of those aged 17 and under lacked 
coverage, versus 27.4 percent of those aged 18 to 24 and 15.5 
percent of those aged 25 to 44. .Among those aged 17 and 
under, 14 percent of whites lacked coverage, compared to 18.9 



percent of blacks. Among those 17 and under living in families 
with incomes below the poverty 7 level, the percentage was 32.5 
without coverage versus 9.6 percent for those above the 
poverty level. Data from a 1988 survey show that 30 percent of 
Hispanics aged 17 and under lacked coverage, more than ei- 
ther whites or blacks. 

Other data linking socioeconomic status with reduced ac- 
cess to care include the percentage of Americans with a regu- 
lar source of primary care. A regular source of care is defined 
as a particular clinic, health center, doctor's office, or other 
place to which a person goes to obtain health care or health 
advice (other than an emergency room). In 1991, 81.9 percent 
of Americans not in poverty and 72 percent of those in 
poverty had a regular source of care (Fig. 23). Among minori- 
ties, 67.9 percent of Hispanics not in poverty had a regular 
source of care, compared to 57.6 percent of Hispanics in 
poverty. For blacks not in poverty, 81.5 percent had a regular 
source of care, compared to 77.7 percent of blacks in povertv. 
Among whites, 82.4 percent not in poverty and 70.4 percent 
of those in poverty had a regular source of care. 

The gap in access to a regular source of care was 9.9 percent 
between those in povertv and those not in poverty in 1991. 



Figure 23. Percentage off People With a Regular Source of Care, 1991 



Not in Poverty 



In Poverty 




White Black Hispanic Total 

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey 



1^ 



Prevention '93/94: Federal Programs and Progress 



among the population not in poverty, 18.1 percent — 
over 45 million people — did not have a regular source ot care. 
At the other end ot the spectrum, 52.1 percent ol 1 lispanics in 
poverty did not have a regular source ot care. 

One prow measure ot access to care and the potential bene- 
fit ot preventive services is prenatal health care. Early and reg- 
ular prenatal cue. including education and counseling, can re- 
duce the likelihood ot low birth weight and other perinatal 
complications — key factors in infant mortality. \n expectant 
mother with no prenatal care is 5 times as likeh to have a low- 
birth-weight baby, yet women in high-risk groups, such as 
adolescents and low -income women, are among the least 
likely to receive early prenatal care. 

From 1970 to 1990, the proportion ot all mothers who 
began prenatal care during the first trimester of pregnancy in- 
creased trom 68 to 75.8 percent. Among whites, the increase- 
was from 72.3 to 79.2 percent; among blacks, trom 44.2 to 
60.6 percent; anil among American Indians and U.iska Na- 



mes, trom is. 2 percent in to 57.9 percent. Almost all of this 
improvement in access to prenatal care was achieved during 
the 1970s; data lor the P'SOs present stagnation anil even de- 
cline in this important health status indicator. The overall 
population rate dropped slightly trom 1980 to 1990; the white 
and Hispanic rates were unchanged; the black rate decreased; 
and the American Indians and \l.iska Natives rate improved 
slightly. 

The gap in both early and late prenatal care between whites 
and other racial .\nA ethnic groups remained significant in 
1990. In 1990, 6.1 percent of all mothers began prenatal care 
only in the third trimester or received no care prior to delivery. 
Among whites, this percentage was 4.9, versus 11.3 among 
blacks, [2.9 among American Indians anil Alaska Natives, 12 
among Hispanics, and 5.8 among \suns and Pacific Islanders. 
I hese percentages represent increases since 1980 ol 2(1 percent 
tor the general population. 14 percent lor whites, and 27 per- 
cent tor blacks; the 1 bspanic rate remained unchanged. 



Figure 24. Percentage off Pregnant Women Receiving First Trimester Prenatal Care, 
by Race and Hispanic Origin, Selected Years, 1970-1990 



White 



72 3 



Asian/Pacific Islander 



75.8 
75.1 



«.'"* Total 



Black 
* 602 Hispanic 



American Indian/Alaska Native 

55.8 579 



7^ 

44.2 



38.2 



1970 1980 1990 

Source: Centers for Disease Control and Prevention. National Center for Health Statistics. National Vital Statistics System 



Ea 



Health Status Trends 



Immunization 

The reduction in incidence of infectious disease is the most 
significant public health achievement of the past 100 years. 
Most of the gains in control of infectious diseases, including 
the virtual elimination of diphtheria and poliomyelitis in the 
United States, have resulted from improvements in basic hy- 
giene, food production and handling, and water treatment, but 
another major factor has been the development and wide- 
spread use of vaccines, which are among the safest and most 
effective preventive measures. 

Notwithstanding the progress that has been made, infec- 
tious diseases remain important causes of illness and death in 
the United States. Even though the Nation's leading causes of 
death among the general population are now chronic diseases, 
the top 10 killers among children aged 1 to 4 include pneumo- 
nia and influenza, HIV infection, septicemia, and meningitis. 



In addition, racial and socioeconomic disparities persist in 
child immunization status. According to the National Health 
Interview Survey (NHIS), the ranges of immunization status 
in 1991 showed that black immunization rates were as much as 
27 percent lower than those for whites. Data showed that im- 
munization rates for those below the poverty level were as 
much as 23 percent lower than those at or above the poverty 
level. Finally, data showed that immunization rates for urban 
populations were as much as 18 percent lower than those for 
suburban and rural populations. 

The Healthy People 2000 objective for children under the 
age of 2 is for 90 percent to be up-to-date on the basic series of 
immunizations. Figure 25 gives a state-by-state analysis based 
on the State Immunization Survey by CDC. NHIS data for 
1991 for the basic immunization series among children showed 
that only 37 percent of children aged 24 to 35 months were 
fully immunized. Clearly, childhood immunization is an area 
where substantial and organized effort needs to be focused. 



Figure 25. Up-to-Date Immunization Status* of School Enterers** 
at the Second Birthday, United States, 1991-1992 




_| Did not report 



50% - < 60% fc-^<j S 70% 

60% - < 70% 



* 4 DTP, 3 Polio, 1 MMR; data obtained retrospectively from records at time of school entry 
' North Dakota and Tennessee results from children 2 years of age, 1991 
Source: Center for Disease Control and Prevention, National Center for Preventive Services, State Immunization Survey 



© 



Prevention '93/'94: Federal Programs and Progress 



Chapter 



Agency 
Innovations 



promotion and disease prevention programs 
sponsored by the Department of Health and 
Human Services and other Federal agencies. 
Prevention initiatives range from basic and applied research to direct 
delivery of services; from sponsorship of health information and educa- 
tion to data collection, analysis, and dissemination; and from enhance- 
ment of the capacity of private sector organizations to conduct preven- 
tion activities to establishment and enforcement of safety standards. 

As highlighted in this chapter, the Federal Government — often with 
interagency collaboration and often in collaboration with State and local 
governments and national and community organizations — is an impor- 
tant contributor to the national commitment to a healthier America. The 
progress and achievements depicted in the following program summaries 
are characterized by a determined and collective effort of individuals, 
organizations, and governments on behalf of health promotion and 
disease prevention. 



© 



Prevention '93/'94: Federal Programs and Progress 



Department of Health and Human Services (DHHS) 



Public Health Service (PHS) 

Office of the Assistant Secretary 
for Health (oash) 






© 



he Assistant Secretan for Health is re- 
sponsible for overseeing the work ol the 
Public Health Service. Described in this 
chapter are the health promotion and dis- 
ease prevention policies and programs of 
M the eight offices in the Office of the Vssis 

t.int Secretan 1 tor I lealth .mil the eight agencies of the Public 

I le.ilth Service. 



National Vaccine Program Office 
(nvpo) 

The National Vaccine Program was established in 1987, 
under Title XXI of the Public Health Senate Act, to assume 
leadership responsibility for the Nation's vaccine and immu- 
nization programs. Specifically, it was established to coordi- 
nate and provide direction lor each element ol the immuniza- 
tion process: vaccine development, tcstinu for safety and 
efficacy prior to licensure, licensing, production, procure- 
ment, distribution, delivery, and continued evaluation of vac- 
cines in use after licensure. Through collaborative efforts with 
the Centers for Disease Control and Prevention (CDC), the 
Food .md Drug Administration (ID \), the National Institutes 
of] le.ilth (Nil 1 1, the 1 lealth Resources and Services Admmis 
nation 1IIRSA1. the I .S. Agency tor International Develop- 
ment (USAID), and the Department of Defense (DOD), the 
program seeks to assure vaccine availability and use, and to 
identity' and resolve vaccine supply and delivery system prob- 
lems. The law also requires that the program ensure govern- 
mental and nongovernmental production and procurement of 
sate and effective vaccines. In addition, NATO provides tech- 
nical and scientific advice to the Vaccine Injun' Compensation 
Program under which the Federal Government will pay com- 
pensation on a no-fault basis to persons injured by vaccines or 
who suit ot vaccines. 



NVPO Prevention Highlights 

\\ l'( ) coordinates kev Federal strategics in disease preven- 
tion and health promotion to meet 1)1 II IS and PI IS goals, 
III ■ \l I in Pi (it'll 2000 established health objectives for the 
Nation for the year 200(1. Major immunization goals in this 
report are to increase childhood immunization levels to at 
least 90 percent for 2 -year-old children; to eliminate measles, 
diphtheria, poliomyelitis, rubella, and tetanus; and to substan- 
tial!) reduce the cases ot pertussis and mumps. 

The National Vaccine Plan. \\ I't >. with the PHS, has de- 
veloped a comprehensive National Vaccine Plan to provide 
direction and coordination to public agencies, the private sec- 
tor, voluntary organizations, and industry. Legislation re- 
quires that the plan seek to assure that everyone who should 
be protected by vaccination receives all recommended vac- 
cines, that needed research expertise is directed toward im- 
proving existing vaccines, that development of new vaccines is 
encouraged to extend preventive health services even further, 
that safety and effectiveness ot vaccines and immunization is 
ensured, and that support is provided tor global immunization 
efforts. The plan is the basis for the President's Childhood 
Immunization Initiative. 

Plan To Improve Access to Immunization Services. An 
Interagency Committee on Immunization convened by 
NVP( ) is implementing a plan to improve the Nation's access 
to immunization sen ices. This plan consists of the implemen- 
tation steps developed in the National Vaccine Plan (above). It 
is designed to improve the Nation's access to immunization 
sen ices through improved coordination of established Federal 
health, income, housing, educational, and nutritional pro- 
grams. The plan is focused on improving immunization ser- 
vices tor preschool-age children and targeting resources to 
high-risk and hard-to-reach populations. 



Agency Innovations 



The Children's Vaccine Initiative (CVT). The goal of this 
initiative is to improve preventive health care for children 
through improved vaccines and enhanced immunization prac- 
tices. Research is being conducted to achieve this through 
fewer doses of vaccines, alternative means of administration, 
and combined vaccines. Immunization coverage should im- 
prove while requiring fewer visits to health care providers. Ex- 
perience suggests that the greater the number of contacts re- 
quired to fully immunize a child, the less likely it is that the 
child will be fully immunized. This is particularly important 
among children in die inner city and the rural poor. 

The National Vaccine Advisory Committee (NVAC). 

NVAC is comprised ot national, State, and local healdi offi- 
cers, health practitioners, university physicians, and con- 
sumers who advise PHS on vaccine issues. In 1991 NVAC re- 
leased a report entitled "The Measles Epidemic: The Problems, 
Barriers and Recommendations" and followed it with a report 
entided "Access to Childhood Immunizations: Recommendations 
and Strategies for Action. " These reports describe what the Na- 
tion as a whole must do to achieve its immunization goals. 
Identified are areas for additional action by all levels ot the 
public sector, including Federal, State, and local governments, 
and the private sector, including physicians, health insurance 
companies, and parents. 

The PHS Action Plan for Women's Health. This plan ad- 
dresses preventive health care concerns of women. Immuniza- 
tion goals included in this initiative are intended to (1) increase 
the proportion of primary care providers who give appropriate 
information and counseling about immunization to women of 
reproductive age and the elderly, (2) increase the availability of 
vaccines for women, (3) incorporate immunization for disease 
prevention into substance abuse treatment and prevention pro- 
grams, and (4) stimulate the recruitment of women to partic- 
ipate in the development of vaccines for women's diseases. 



Office of Disease Prevention and 
Health Promotion (odphp) 

The Office of Disease Prevention and Health Promotion 
(ODPHP) was established in 1976 to provide leadership for 
disease prevention and health promotion among Americans by 
stimulating and coordinating Federal activities. ODPHP ad- 
vances this mission by working to strengthen the disease pre- 
vention and health promotion priorities of the U.S. Depart- 
ment ot Health and Human Services (DHHS) within die 
collaborative framework of the Public Health Service (PHS) 
and DHHS agencies. Through effective communication, coor- 
dination and coalition-building, ODPHP also provides a 
framework for collaboration among Federal, State, and local 
government agencies, professional and voluntary organiza- 
tions, health care providers, employers, insurers, and academia. 
This report details ODPHP's major accomplishments and ac- 
tivities during 1992 and presents key initiatives for 1993. 

ODPHP Prevention Highlights 

Implementation of HEALTHY PEOPLE 2000 has begun na- 
tionwide. Three overarching goals and 300 specific objectives 



are to be achieved by the year 2000. ODPHP is responsible 
for coordinating the development progress and outcome of 
these objectives. The first round of PHS-wide Progress Re- 
views covering all 22 priority areas was completed. Progress 
reviews have begun that cut across these priority areas to focus 
on the health disparities of special population groups. 

The Healthy People 2000 Consortium, comprised of na- 
tional organizations and State and territorial health depart- 
ments, now has over 330 members. A database of members' 
activities was developed to identify groups working on partic- 
ular issues, as well as potential channels for reaching the di- 
verse constituencies represented by the Consortium. At the 
1993 national meeting, members learned about opportunities 
for action in the health care reform era. An activities sampler, 
Turning Commitment into Action, was distributed. 

More than 7,500 copies of the Healthy People 2000 Action Se- 
ries (including Public Health Sei-vice Action, State Action, and 
Consortium Action), which describes efforts underway to achieve 
the objectives by government and private organizations, have 
been distributed. The Healthy People 2000 Fact Sheet and Re- 
source Lists — one for each priority area — were revised. UP- 
DATE, a supplement to the bimonthly Prevention Report, was 
developed to report on programs and activities directly related 
to achieving the goals of HEALTHY PEOPLE 2000. To support 
implementation of HEALTHY PEOPLE 2000 across the country, 
an electronic network is being established. Among other ele- 
ments, the network will include the consortium database, a di- 
rectory of information resources related to the national objec- 
tives (including data sources), full texts of all key HEALTHY 
PEOPLE 2000 documents, and a bulletin board permitting com- 
munication among users. In die pilot stage, the network will be 
available to HEALTHY PEOPLE 2000 Consortium members and 
health officials at the Federal and State levels. 

Put Prevention Into Practice, a national preventive services 
education campaign, is entering its implementation phase. Put 
Prevention Into Practice: Education and Action Kits, as well as in- 
dividual kit components, will soon be available through the 
Government Printing Office and major national primary care 
provider groups. The patient component of die campaign, the 
passport-sized Personal Health Guide, was introduced in June 
1992 in New York City. This 3 2 -page booklet allows patients 
and providers to assess risk factors and plan an individualized 
schedule of preventive services. Other elements of the initia- 
tive, the Child Health Guide, and the Clinician s Handbook for 
providers, and materials for use in the office or clinic setting, 
have now been developed. Implementation through national 
primary care provider groups, private sector partners, and 
health professional educational settings, is underway. 

The Dietary Guidelines for Americans provide recommenda- 
tions based on current scientific knowledge about how dietary 
intake can reduce risk for major chronic diseases. During 
1992, DHHS and the U.S. Department of Agriculture 
(USDA) issued the "Food Guide Pyramid" graphic, a pictorial 
representation of the concepts presented in the Guidelines, and 
developed Building the Future: Nutrition Guidance for Child Nu- 
trition Programs, which provided dietary guidance for child nu- 
trition programs. Work began on the fourth edition of the Di- 
etary Guidelines, which will be issued joindy by DHHS and 
USDA in 1995. 

The 1993 ODPHP nutrition activities include preparation 
of a follow-up report to the Surgeon Generals Report on Nutri- 
tion and Health focusing on dietary fat and health. Two publi- 



Prevention '93/94: Federal Programs and Progress 



canons on worksite health promotion were issued. Worksite 
Nutrition: A Guide to Planning, Implementation, and Evaluation 
u.is .1 joint effort with the American Dietetic Association. The 
second is a companion document and a "how-to" manual of 
the DHHS Healthy Menu Program. The annual DHHS nu- 
trition symposium, held in recognition of National Nutrition 
.Month in .March, had as its theme "Nutrition and Multimedia: 
Exploring New Options." In addition, ODPHP helped coor- 
dinate DHHS participation in the International Conference 
on Nutrition in December 1992. 

Actuarial projections ot the costs of clinical preventive ser- 
vices were developed in aire- and gender-specific packages. 
Using these cost estimates, a monograph titled The Compara- 
tive Ban- fits Modeling Project: A Framework for Cost-Utility 
Analysis of Government Health Care Programs was published. 
( M)P1 IP provides support for an lntradeparuncni.il Group on 
the Cost-Effectiveness ol Clinical Preventive Services and a 
non-Federal expert panel to review methodologic issues in 
cost-effectiveness analysis ot clinical preventive services. 

The U.S. Preventive Services Task Force is continuing its 
work, updating and expanding its 1989 report, the tjtuJe to 
Clinical Preventive Services. Background papers lor the second 
edition ot the report appeared in the / !>i American 

Medical Association, and the second edition ot the Guide to Clin- 
ical Preventive Services will be published in 1994. 

The 1 992 National St, rksite Health Promotion 

itieswas released at the \pnl 1993 meeting of the National Co- 
ordinating Committee on Worksite Health Promotion. 
Among the 1,507 private worksites surveyed, significant in- 
creases were reported in worksite activities such as nutrition, 
weight control, physical fitness, high blood pressure, and stress 
management compared to a 1985 ODPHP worksite survey. In 
1992, SI percent of the worksites offered at least one health 
promotion activ itv (other than a formal smoking policy). 

ODPHP strengthened its national health promotion and 
disease prevention activities through the work of three Na- 
tional Coordinating Committees that address cluneal preven- 
tive services, worksite health promotion, and health promo- 
tion through the schools. Committee members include 
representatives from private organizations and Federal agen- 
cies. The Secretary's Council on Health Promotion and Dis- 
ease Prevention held three meetings during 1992 on 
HEALTHY PEOPLE 2000 implementation activities, clinical 
preventive sen ices, and school health. 

The ODP1 IP National I Iealth Information Center (NHICl. 
congressionally mandated to provide leadership regarding 
health information issues, is being expanded to address die im- 
plications of technological developments on the information in- 
UCture ami interactive media on health information. 
N11IC. which responded to over 32,000 information requests 
in 1995. will focus increasingly on promoting decentralized and 
coordinated health information dissemination through bodi 
electronic channels and community-based channels such as li- 
braries. A New Media Projects group will seek to promote ef- 
fective applications of the new media for public health informa- 
tion and education. 

ODPHP also began the development of a national Confer- 
ence on Networked Health Information. The conference, 
preceded by a series of workgroup meetings, will prepare ac- 
tion recommendations for the Federal Government and kev 
private sector institutions regarding health information and 
the emerging communications infrastructure. 



PI IS continued to support the Community Sen ices Work- 
station Network, a research project aimed at learning how 
modern computer and communication technologies cm sup 
pon and enhance the coordination of health and human ser- 
vices at the community level. The network, which will com 
bine electronic communication capabilities with information 
retrieval and analysis tools, was designed to aid a coalition ol 
health and human sen ices providers in die District ot Colum- 
bia in their efforts to work collaborativel) to serve at-risk indi- 
viduals and families. \ pilot network, linking 15-20 agencies, 
is scheduled tor implementation in early 1994. 

Publications completed by ODPHP, or through coopera- 
tion with other organizations, in L992 include: 

Promoting Healthy Diets and Active Lifestyles to Lower-SES 
iults 

Healthy Schools: . I Directory of Federal Programs and Activities 
Related to Health Promotion Through the Schools 

Healthy Worksites Directory of Federal Initiatives in Worksite 
Health Promotion 

Measurement of Physical Fitness: . I Historical Perspective 

('DPI IP collaborated with the following organizations: 
\\ ashington Business ( iroup on Health to continue manag- 
ing the National Resource Center on Worksite 1 Iealth Promo- 
tion; the National ( ivic league's I lealihy Communities Ac- 
tion Project, which seeks to improve the quality ol life anil the 
general health ot individuals through the development ot inno- 
vative approaches to health promotion and disease prevention; 
and the Voluntary Hospitals of America, Inc. to help with 
the design and implementation ot' the Put Prevention lino 
Practice national preventive services education campaign. 

ODPHP participated in cooperative agreements with the 
following organizations: American College of Preventive 
Medicine. Association of Teachers ol Preventive Medi- 
cine, National Medical Association, and American Insti- 
tute ot Nutrition. 



Office of International Health 
(oih) 

The Office of International Health (Oil I) provides leader- 
ship, formulates overall policy, and assures coordination of 
1)1 11 IS's international health activities. These include cooper- 
ative relationships with multilateral health organizations, nu- 
merous bilateral programs with other countries, and coopera- 
tive activities with other Federal agencies, primarily the U.S. 
Agency for International Development (USA1D). Opera- 
tionally, international programs are carried out as extensions 
of PI IS agencies' domestic efforts. 

OIH Prevention Highlights 

Bilateral Relationships. Prevention-related research activi- 
ties are conducted under a number of bilateral health agree- 
ments, including those with China, India, Poland, Russia, and 
Egypt among others. For example, nine prevention-oriented 
projects with Egypt include genetic counseling, monitoring of 
rural populations for hypertensive diseases, identifying indi- 
viduals at risk for developing heart disease, counteracting the 
growing threat of filariasis, and development of diagnostics 
and improved vaccines for prevention and control of acute 
respiratory infections in children. 



Agency Innovations 



The Indo-U.S. Vaccine Action Program (VAP) has been an 
important mechanism for promoting research to develop new 
or improved vaccines and immuno-diagnostics. AIDS and tu- 
berculosis are also included under the VAP. An NIH contract 
was awarded to a U.S. university for cooperation with the In- 
dian Council for Medical Research to establish a study site for 
evaluation of AIDS vaccines when they become available. Co- 
operative efforts with selected African countries are being 
strengthened to include malaria control, STD-HW linkages, 
and prevention of AIDS. 

Multilateral Relationships. DHHS plays a key role in U.S. 
relations with multilateral health organizations, including the 
World Health Organization, the Pan American Health Orga- 
nization, the International Agency for Research on Cancer, 
the United Nations Children's Fund, and others. Many of the 
program efforts of these organizations are focused on preven- 
tion. These include immunization, oral health, safe mother- 
hood, cancer reduction, cardiovascular disease, and promotion 
of healthy lifestyles among youth and children. 

In 1992, the World Health Organization (WHO) estab- 
lished as a goal the eradication of polio by the year 2000. The 
PHS, notably, the Centers for Disease Control and Preven- 
tion (CDC), is providing technical, laboratory, and program- 
matic assistance to WHO in support of this initiative. CDC 
epidemiologists were detailed to WHO offices in China and 
the Philippines to provide technical assistance. A polio out- 
break was investigated in Jordan, an automated surveillance 
system was developed in China, and CDC assisted with analy- 
sis of data from research projects in Cote d'lvoire, Morocco, 
Oman, the Gambia, Brazil, and Thailand. These research pro- 
jects are part of efforts to improve the effectiveness of oral 
polio vaccine. Polio eradication will lead to permanent im- 
provements in overall immunization delivery, disease control, 
and primary health care. 

In 1993, PHS international program efforts provided assis- 
tance to HIV/AIDS/STD research and interventions in devel- 
oping countries of Africa, Asia, and Latin America. The over- 
all goals of various activities were to advance global 
understanding of the epidemiologic characteristics relevant to 
HIV/MDS/STD prevention and to develop and test different 
prevention technologies in developing country settings. Vari- 
ous types of HrWAIDS-related training for health profession- 
als was provided. PHS played an important supportive role in 
1992, through WHO, for an Organization on African Unity 
Summit on AIDS. 

Assistance to the Newly Independent States (NIS)/Russia. 

FDA and OIH, in cooperation with the U.S. Agency for In- 
ternational Development (USMD) and the Department of 
State, are providing technical assistance to NIS/Russia in im- 
proving their capacity for quality control of locally produced 
vaccines. 

A workshop on the principles of regulatory control public- 
health agencies was held in Russia in 1993 to demonstrate how 
such agencies can ensure that only safe and effective vaccines, 
drugs, and medical devices enter the health care system. 



Office of Minority Health 



The Office of Minority Health (OMH) is the focal point 
within DHHS for developing policy on issues related to im- 
proving die health status of the American Indian/ Alaska Na- 
tive, Asian American, Black, Hispanic, and Pacific Islander 
populations. OMH was established administratively in 1985 
and was subsequently provided with a formal legislative man- 
date by the Disadvantaged Minority Health Improvement Act 
of 1990, Public Law 101-527. 



OMH Prevention Highlights 

Office of Minority Health Resource Center (OMHRC). 

The OMH Resource Center was established in 1987 to facili- 
tate exchange of information on minority health topics, help 
identify information gaps, and provide technical assistance in 
information dissemination. OMHRC maintains a computer- 
ized data base of minority health-related materials, organiza- 
tions, programs, and funding sources. The data base also in- 
corporates a Resource Person Network, which is used to link 
professionals who are knowledgeable about minority health 
with community-based organizations, voluntary groups, and 
individuals needing technical assistance in health areas. 

Minority Community Coalitions Health Demonstration 
Grants. The Minority Community Health Coalitions 
Demonstration Grant Program provides opportunities for 
community capacity building through the development of mi- 
nority health coalitions which conduct prevention interven- 
tions. Emphasis has been placed on HrWAIDS and the six 
priority areas identified by the 1985 Secretary's Task Force 
report. In 1991, the program was expanded to allow coalitions 
to develop programs about other health problems critical to 
their communities. 

Minority Male Grants. In 1990, DHHS created the Minority 
Male Initiative to focus on ways to improve services to minority 
males at high-risk of multiple health and social problems. A Mi- 
nority Male Grant Program, jointly funded by other DHHS 
agencies, is administered by the Office of Minority Health. The 
Minority Male Grant Program addresses (1) health problems 
such as alcohol, tobacco, and other chemical dependency; 
homicide, suicide, and unintentional injuries; HIV infection 
and sexually transmitted diseases; and mental health problems; 
and (2) social problems such as unemployment, under-educa- 
tion, poor social development, homelessness, family dysfunc- 
tion, child abuse and neglect, delinquency, criminal back- 
grounds, or teenage pregnancy and fatherhood. The grant 
program consists of three components: conference grants, 
coalition development grants, and coalition intervention grants. 
In FY 1992, 21 conferences, 12 coalition developments, and 4 
coalition intervention demonstration grants were awarded. 

HIV/AIDS Education/Prevention Grants. The Minority 
HIV/AIDS Education/Prevention Grant Demonstration 
Grant Program supports projects that demonstrate health ed- 
ucation and prevention strategies that help to eliminate or re- 
duce the risk of acquiring or transmitting HrV virus, and 
other HIV-related health problems such as sexually transmit- 
ted diseases, tuberculosis, and substance abuse. A Los Angeles 



o 



Prevention '93/94: Federal Programs and Progress 



Minority AIDS Project was awarded in FY l c,l) J and contin- 
ued to receive funds in F\ 1993. 
Effective FY 1993, the OMH Minorit) Hl\ UDS Educa- 
Prevention Grant Program was transferred to the 
Centers for Disease Control and Prevention's Cooperative 
Agreement Program for Minority Community-Based Organi- 
zations (CBOs). CDC expanded the scope of its minority 
CBO announcement to include low-, intermediate-, and high- 
prevalence I1IV areas to allow CBOs throughout the country 
to compete lor program resources. 

A Critical Review of the Status and Trends in the Health 
and Qualitx of Life of Minorit) Populations. OMH 
dating and expanding the information included in the 1985 Re- 
■ the Secretary's Task Force on Black and Minority Health. 
There are three components of the "Critical Review": (1) a 
quantitative assessment of excess deaths and mortality rates lot- 
each racial and ethnic minority population since the 1985 I ask 
force Report: (2) establishment of baseline data on morbidity, 
disability, and quality ol life issues tor each racial and ethnic 
minority population, with establishment of baseline data: and 
( i) enhance the PI IS's ability to track trends and health indices 
related to racial/ethnic populations. This report will provide 
more comprehensive analyses lor all racial/ethnic minority 
populations due to improvements in data collection made since 
1985 [n addition to a discussion of mortality in minority popu- 
lations, other measures of health status will be examined. 

PUS I ask lone ..n Minority Health Data. 1 he PUS Task 
Force on Minorit) Health Data was established in January 
1991 tn conduct a short-term, forward-looking, policy-ori- 
ented review ol minority health data plans and activities. Ibis 
task force was co-chaired by representatives from OMH. 
\C1IS. and the PI IS Office of Data Policy. Following review 
of data issues related to minorit) health, a directory of minor- 
ity health data resources within the PI IS was prepared, as well 
as recommendations for addressing high priority data needs. 
Both of these reports were published by OM1I during FY' 
1993. PHS agencies are currently developing plans to imple- 
ment the recommendations, and are collaborating to improve 
the collection and analysis of minority health data. 

Minority Health Tracking System (MHTS). OMH is de- 
signing a Minority Health Tracking System that will contain 
information on grants ami contracts related to minority health 
that are supported by PI IS. The first product of the All II S 
Programmatic Database is a "Catalog of Selected U.S. Public 
I lealth Sen ice Projects Targeting Racial and Ethnic Minority 
Populations: FY 1989/1990," which includes project sum- 
maries ot PHS projects targeted at minority populations in 10 
priority health issue areas identified by OMH: cancer, cardio- 
vascular disease anil stroke; diabetes; HIY/AIDS; infant mor- 
tality and low birth weight; substance abuse and chemical de- 
pendency: homicide; suicide and unintentional injury; health 
care access, delivery, and financing; health professions devel- 
opment; and health data collection and research methodology. 
The statistical data base, currently under development, will 
provide data summaries on health issues of concern to minor- 
ity populations. 



National AIDS Program Office 
(napo) 

The National AIDS Program Office (N U'O) serves as the 
senior policy office to the Assistant Secretary for Health 
I \S1 h and the focal point for coordination and integration of 
the Public Health Service (PITS) efforts to prevent and con- 
trol the occurrence and spread ol IIIV infection and .AIDS. 
\ U'O serves as the lead agency to coordinate the HEALTHY 
PEOPl I 201ID priority area on 111Y infection. NAPO provides 
oversight of PI IS's I LTV/AIDS programs and research, identi- 
fying essential areas ot collaboration tor greater efficiency and 
more rapid progress. 

Planning HIV/AIDS Goals. In its planning role. NAPO 
serves as the lead in identifying long range planning strategies 
that are critical to allocating PI IS 1 [TV/AIDS resources over 
the course of the epidemic. In its analytical and informational 
roles. NAPO assists \S1 1 in responding to critical and fast- 
breaking HIV UDS-related issues. NAPO provides leader- 
ship in national planning for UDS surveillance, prevention, 
research, and sen ices; 

• To establish multi-year functional strategies to combat 
HlY.md UDS; 

• To charge each PHS agency and appropriate OAS1 1 
Staff office to develop and implement a detailed or "tac- 
tical" plan that expands upon this broader PHS plan; 
anil. 

• To disseminate, to the State and local governments, 
other Federal departments and agencies. Congress, and 
the public, information about PlIS's strategies and ef- 
forts to combat 1 11V and UDS. 

The planning process extends to budget formulation and 
monitoring. These activities provide direction and feedback 
lor adjustments of both planning and policy. 

I xlernal Liaison. In a liaison role, NAPO plans and collabo- 
rates with other Federal departments, agencies, voluntary 
health organizations, advocacy groups, community-based or- 
ganizations, and professional societies, among others, on rec- 
ommendations that address cross cutting issues and policies. 

NAPO Prevention Highlights 

Institute of Medicine (IO.M) Roundtablc for the Devel- 
opment of Drugs and Vaccines Against AIDS. Through an 
intra-agency agreement with the Department of Veterans Af- 
fairs, NAPO provides support to the IO.M. The purpose of the 
roundtablc is to identify and help resolve impediments to the 
availability ot sate and effective drugs and vaccines for 
HIY/AIDS. 

National Congress of American Indians (NCAI). Through 
an intra-agency agreement with the Administration for Native 
Americans, NAPO provided support to NCAI — the oldest na- 
tional tribal organization in the Linked States, which repre- 
sents over 350 American Indian tribes and Alaska Natives. 
The purpose of the NCAI contract is to conduct the first Na- 
tional American Indian AIDS summit for educating tribal 
leaders on AIDS/HIV prevention at the tribal level; to work 
with tribal leaders and governments in the development and 



Agency Innovations 



adoption of resolutions addressing the special needs of in- 
fected tribal members, including access to health care and 
housing in urban, rural, and remote tribal settings; and to de- 
velop HIV/ AIDS educational material in native languages. 



family planning information and education materials, and re- 
search to improve delivery of family planning services. The 
program provides support for 4,000 clinics that serve approxi- 
mately 4 million women and about 90,000 men each year. 



Office of Population Affairs (opa) Office on Women's Health (owh) 



The Office of Population Affairs (OPA) administers the 
Title XX Adolescent Family Life Program and the Title X 
Family Planning Program. The activities of both programs are 
primarily preventive in nature. OPA serves in an advisory ca- 
pacity to the Secretary, through the Assistant Secretary for 
Health, on policy and legislative issues; prepares reports on 
departmental and interdepartmental activities; and works in 
cooperation with other Federal agencies and concerned orga- 
nizations in the area of population research and family plan- 
ning services, training, and education. OPA serves as the lead 
agency for coordinating the HEALTHY PEOPLE 2000 priority 
area, family planning. 

OPA Prevention Highlights 

Office of Adolescent Pregnancy Programs. Adolescent sex- 
ual activity has increased in the last 10 years. There are an es- 
timated 1 million adolescent pregnancies each year. In 1990, 
there were 533,483 births to adolescents — 521,826 to girls 
aged 15-19 years and 11,657 to girls under 15 years of age. 
Adolescents are less likely to receive early prenatal care and 
are somewhat more likely to have low-birth-weight infants 
than women in their twenties. 

Under Title XX of the Public Health Service Act, the Of- 
fice of Adolescent Pregnancy Programs funds demonstration 
programs that test prevention services to encourage adoles- 
cents to postpone sexual activity and for providing care ser- 
vices for both pregnant and parenting adolescents. A major 
focus of the legislation for both the prevention and care com- 
ponents is an emphasis on family involvement. In addition, the 
Adolescent Family Life Program funds research on the deter- 
minants and consequences of adolescent pregnancy to facili- 
tate a better understanding of these serious problems. A sum- 
mary of projects is available. The program is currently funding 
37 model demonstration projects and seven research projects. 
A broader mission for the program is planned to ensure a focal 
point for coordinated, comprehensive support to improve 
adolescent health. 

Office of Family Planning. The Title X Family Planning 
Program grants funds for voluntary family planning services 
which include natural family planning, infertility services, ser- 
vices for adolescents, and family involvement. The program is 
designed to provide family planning services primarily to low- 
income individuals. To attain better data regarding demand 
for and use of family planning services, a new clinical data sys- 
tem was developed in 1993. A minority health study was con- 
ducted within Title X clinics to determine the level of minor- 
ity leadership and staff. The results of this study were 
published in 1993 in cooperation with the National Family 
Planning and Reproductive Health Association. Within its 
training program, Title X has set aside special grant funds to 
increase the training of minority family planning nurse practi- 
tioners. The Title X program also funds the development of 



The Office on Women's Health (OWH) was established in 
1991 to advise the Assistant Secretary for Health on women's 
health issues and to coordinate women's health policies and 
programs across PHS agencies, offices, and regions. Other ac- 
tivities include monitoring implementation of the PHS Action 
Plan for Women's Health, promoting a PHS regional women's 
health agenda, and providing administrative and staff support 
to the PHS Coordinating Committee on Women's Health Is- 
sues. OWH serves as a co-lead on the HEALTHY PEOPLE 2000 
work group on women. 

OWH Prevention Highlights 

PHS Action Plan for Women's Health. This key document 
provides a goal-driven blueprint for improving women's 
health in the areas of prevention, treatment and service deliv- 
ery, research, and education and training. The plan identifies 
goals and action steps for priority health issues, including ac- 
cess to health care, participation in research, mental health, 
reproductive health, acute and chronic illnesses, and lifestyle 
behaviors. 

PHS Action Plan for Women's Health: 1991 Progress Re- 
view. This document, the first in a series of annual reviews, 
identifies the status of initiatives undertaken by PHS agencies, 
offices, and regions to address women's health issues. Special 
attention is given to accomplishments, ongoing activities, and 
modifications to each of the goals and action steps outlined in 
the plan. Achievements include: 

• The Alcohol, Drug Abuse, and Mental Health Adminis- 
tration (reorganized into the Substance Abuse and Men- 
tal Health Services Administration) addressed the needs 
of pregnant and post-partum women and infants ex- 
posed to alcohol and other drugs; supported investiga- 
tions on gender differences for mental health conditions 
(e.g., depression, anxiety, eating disorders); and spon- 
sored public housing demonstration grants that provide 
preventive and treatment services for women exposed to 
alcohol and other drugs; 

• The Agency for Health Care Policy and Research im- 
plemented guidelines for ensuring the inclusion of 
women in all clinical research grant solicitations; devel- 
oped clinical practice guidelines for mammography, uri- 
nary incontinence, and health care needs of women with 
HIV infection; and expanded research funding to in- 
crease knowledge about health care access for minority, 
low-income, and disabled women; 

• The Centers for Disease Control and Prevention imple- 
mented initiatives to reduce the prevalence of smoking 
among women, especially adolescents; implemented the 
Breast and Cervical Cancer Mortality Act by funding 
State health departments for comprehensive early detec- 
tion programs; and supported initiatives to lower the 
rate of sexually transmitted diseases among women; 



Prevention '93/'94: Federal Programs and Progress 



• The Food and Drug Vdministradon provided con- 
sumers, health professionals, and women's health advo- 

vvith information on medications, breast implants, 
mammography, food labeling, and HIWAIDS; and col- 
laborated with public health educators to develop train- 
ing workshops and media programs: 

• The Health Resources and Services Administration 
vided technical assistance to Ryan WTiite/CARE Act 
grantees to develop standards of care for HIV-infected 
women and families; supported research and demonstra- 
tion projects to reduce the prevalence ol smoking 
among women; and funded a broad range of primary 
and specialty care sen ices for underserved women in 
community and migrant health areas; 

• The Indian Health Service (HIS) enacted a polio to 
provide comprehensive anil continuous prenatal care lot- 
American Indian Alaska Native women; implemented a 
Pap Smear Registry: miA ensured availability of mam- 
mography services tor women in all HIS service areas; 

• The National Institutes of I lealth established an ( )ffice of 
Research on Women's Health to strengthen research on 
health conditions affecting women; implemented a policy 
requiring the inclusion of women in clinical research; and 
launched the Women's Health Initiative, to examine the 
major causes of death, disability, and fr.ultv in women 40 
years ol age and older (heart disease and stroke, breast .mA 
colon-rectal cancer--, ami osteoporosis i. 

PHS Regional Women's Health Vgenda. OUT! is actively; 
i 1 i facilitating the roles ol the women's health coordinators in 
the 10 PHS regions; t2> supporting the development and im- 
plementation of PHS regional women's, health policies, pro- 
grams, conferences and other initiatives: and (3) sharing infor- 
mation on women's health issues. 

PHS Coordinating Committee. Over the past decade, the 
PI IS Coordinating Committee on W omen's I lealth Issues has 
been instrumental in defining and guiding PI IS initiatives for 
meeting priority health needs ol women. OW 1 1 provides ad- 
ministrative and statt support tor the committee, which in- 
cludes membership from the PUS agencies, offices, and re- 
gions, as well as liaisons from other 1)1 II IS operating divisions. 

Women's Health Projects. Due to the greater prevalence of 
illness, disability, and suffering endured by certain groups of 
women. OW"I 1 supported the following special projects: 

• Indian Women's Breast and Cervical Cancer Project — a 
study of the effects of provider attitudes on increased uti- 
lization of breast and cervical cancer screening methods; 

• Women of Color Health Education Coalition Project — 
a multicultural coalition whose goal is health promotion 
through health education programs tor women ot color 
and their families in Boston, .Massachusetts: 

• Transitional Health Program with Incarcerated 
Women — involves development ot a cadre ot interdisci- 
plinary health professionals to provide leadership in the 
delivery ot primary and preventive health care services 
to incarcerated black and Hispanic adolescents; 

• School-Based Preventive Education for Native Ameri- 
can Adolescent Women — provides health education on 
preventable cancers to Native American adolescents. 



President's Council on Physical 
Fitness and Sports (pcpfs) 

The President's Council on Physical 1'itncss and Sports was 
established in 1956 (as the President's Council on Youth Fit- 
ness) to combat poor physical fitness performance among this 
Nation's youth. In 1963, PCPFS responsibilities were ex- 
panded to include the adult population anil sports. PCPFS 
works with other Federal agencies. State and local govern- 
ments, schools and colleges, prolession.il associations, sports 
organizations, -WiA business and industries to carry out its 
mandate. PCPFS serves as the lead agency coordinating the 
111 \l I in PEOPLE 2000 work group on physical activit) and 
fitness. 

PCPFS Prevention Highlights 

On June 22. 1993, President Clinton appointed Olympic 
gold medalist Florence Griffith Joyner and former Congress- 
man loin McAIillen as co-chairs of the PCPFS. Their man- 
date is to advise the Secretary and the President on how we 
can enhance opportunities tor all of our people to participate 
in physical fitness and sports activities. 

Youth Fitness Emphasis. Youth physical fitness continues as 
a top priority. Each new generation, however, laics severe 
cutbacks in school physical education programs and in com- 
munity programs which promote exercise throughout life. 
Several initiatives have been launched to reverse the trend ol 
less physical activnv. PCPFS is continuing to follow-up on 
former Chairman Arnold Schwarzenegger's visits to the 50 
States h\ maintaining contact with and providing technical as- 
sistance to the governors' offices, key educators, and fitness 
leaders in each Stale. 

1 xpanded School Testing Program. The President's Chal- 
lenge Physical fitness 1 est measures muscular strength and 
endurance, cardiorespiratory endurance, agility, and flexibility 
lor students ages 6-17. File Presidential Physical fitness 
Award recognizes those students who score at or above the 
Ssth percentile on all five test items. File National Physical 
Fitness Award recognizes those boys and girls who score at or 
above the 50th percentile. The Participant Physical Fitness 
Award recognizes those students w ho attempt all five test 
items but whose scores I. ill below the 50th percentile on one 
or more of them. Children with physical disabilities are eligi- 
ble for all three awards. One of the motivational programs as- 
sociated with the award is "( )n i our Mark." sponsored by the 
Sugar Association. 

Phvsical Fitness Demonstration Centers. File demonstra- 
tion center program is conducted in cooperation with State 
Departments of Education. States identify elementary and 
secondarj schools that represent the highest quality of physi- 
cal education programs within the State. The schools agree to 
exhibit their programs to visitors, serving as referrals tor peo- 
ple interested in visiting model programs. They receive a 
demonstration center flag and a certificate signed by the chair- 
person of the PCPFS. 



Agency Innovations 



State Champion Award. Each year, the 50 States, the Dis- 
trict of Columbia, Puerto Rico, Guam, and the U.S. Overseas 
Schools are represented in the State School Championship 
Program for Physical Fitness. The competition is divided into 
three classifications, based on enrollment, and three schools 
are selected from each State, based on the percentage of 6- to 
17-year-old children who earn the Presidential Physical Fit- 
ness Award. Winning schools receive a letter and a certificate 
from PCPFS and a State champion shoulder patch for each 
child who wins the award. Announcement of the winners is 
sent to the State Superintendent and Governor, as well as all 
members of Congress, who also recognize the winners. 

National Summer Youth Fun and Fitness Program. 

PCPFS and the National Recreation and Park Association 
(NRPA) jointly sponsor this program, which encourages sum- 
mer participation in fitness activities over a 6-week period for 
6- to 12-year-old boys and girls. Participants receive a booklet 
and a game board at the start of the program and a certificate 
and T-shirt upon conclusion. Begun as a pilot in 9 cities in 
1989, the program expanded to more than 150 cities in 1990, 
1,500 in 1991, and 2,500 in 1992. 

National Physical Fitness and Sports Month. May is Na- 
tional Physical Fitness and Sports Month. Thousands of com- 
munities celebrate in conjunction with National Physical Edu- 
cation and Sports Week, National Running and Fitness 
Week, All Children Exercising Simultaneously, National Em- 
ployee Health and Fitness Day/Federal Fitness Day, and Na- 
tional Osteoporosis Week. 

Leadership Recognition Programs. The Healthy American 
Fitness Leader Awards program, now in its 12th year, recog- 
nizes individuals who have, through personal example and ser- 
vice, promoted the ideals of health and fitness. More than 120 
leaders have been identified, and the program continues with 
AHState Life Insurance sponsorship and L T .S. Jaycees adminis- 
tration. PCPFS also periodically recognizes leadership and 
public service contributions through a series of awards, in- 
cluding the Distinguished Award. 

National Fitness Coalition. A coalition between NRPA and 
PCPFS encourages local park and recreation systems to make 
fitness promotion a priority, increase public awareness of the 
local systems' role in fitness, promote fitness through recre- 
ation, and stimulate cooperative programs and demonstration 
projects. 

Public Information Services. PCPFS distributes a bi- 
monthly newsletter and public service announcements such as 
"Seniors and Fitness" with Milton Berle. A video titled "A Na- 
tion of Winners" was produced to emphasize participation in 
the Presidential Sports Award. 

Federal Sector Programs. The Federal Interagency Health 
and Fitness Council, under the auspices of PCPFS, has en- 
couraged the development of comprehensive programs at 
every level of government to address the issues of preven- 
tion, performance, and safety. Each year, workshops and 
seminars review worksite health promotion initiatives and 
performance. More than 300 government agencies now have 
fitness centers. 



Older Adults. PCPFS's new campaign to promote exercise 
for adults 50 and above is the Silver Eagle Corps. This cam- 
paign is a comprehensive effort to encourage organizations 
and individuals to convey the message that physical activity is 
essential to successful aging. 

Minority Sports and Fitness Focus. PCPFS has fostered a 
pilot program with the Chicago-area Illinois National Guard 
to train fitness volunteers to work with inner-city youth. If 
successful, the project could be replicated in more than 3,500 
communities nationwide with National Guard Bureau facili- 
ties. Also, minority tennis clinics have been conducted in part- 
nership with the U.S. Professional Tennis Registry, the U.S. 
Professional Tennis Association, and the U.S. Tennis Associa- 
tion, the governing body for the sport. One project, Across 
America Tennis Day, was conducted in more than 30 commu- 
nities, emphasizing tennis as a lifetime fitness activity. 

Family Fitness Focus. To encourage family members to ex- 
ercise and eat right, the PCPFS launched "Wake Up! to Fam- 
ily Fitness," with the California Raisins media tour featuring 
Olympic gold medalist Kristi Yamaguchi. A brochure for 
home and school use in the Presidential Sports Award (PSA) 
program was also distributed. PCPFS lowered the entry age to 
6 and added Family Fitness as a new umbrella for nearly 70 
sports/fitness categories. This program is being offered to 
schools nationwide, largely as a noncompetitive inducement 
to be physically active at all ages. 

Fitness and Nutrition. PCPFS co-presented at the 2nd In- 
ternational Conference on Fitness and Nutrition in Athens, 
Greece. A "Declaration of Olympia on Fitness and Nutrition" 
supported the HEALTHY PEOPLE 2000 objectives and the es- 
sential relationship between exercise and nutrition. PCPFS 
also joined with the National Association of Broadcasters 
(NAB) and Kelloggs to create and distribute information on 
the importance of both a good breakfast and exercise. 

PCPFS co-sponsored a March 2, 1993, conference entitled 
"Building Alliances to Communicate Food, Nutrition, and 
Fitness Information to the Public." The overall goals of the 
conference were to bring together the leadership of private or- 
ganizations and government agencies concerned with food, 
nutrition, and fitness to share information on existing pro- 
grams and to determine future needs. 

Native American Initiatives. The first Indian Youth Sports, 
Fitness, and Health Summit was successfully held in Wash- 
ington State with the Yakima Nation and the surrounding 
communities. Supported by more than 35 tribal entities in the 
Northwest, the summit concept will be repeated in the South- 
west as a major gathering of youth. PCPFS is in its 4th year of 
support for the Native Anerican Women's Wellness IV Con- 
ference, as well as the Men's Wellness II Conference. 

National 4-H Fitness Project. In its 7th year, this fitness 
focus for 5.6 million 4-H members, ages 9-19, has resulted in 
a formal agreement between the PCPFS, the USDA's Exten- 
sion Service, and the National 4-H Council. Funded by the 
Sporting Goods Manufacturers Association and supported by 
national exercise, law enforcement, and education groups, the 
workshops have resulted in fitness and food and health pro- 
jects in many State 4-H chapters. 



Prevention ' 9 3 / ' 9 4 : Federal Programs and Progress 



Agency for Health 
Care Policy and 
Research (ahcpr) 



The Agency for Health Care Policy and Research was cre- 
ated by Congress in December 1989. AHCPR serves .is the 
Federal Government's focal point lor health services research. 

AHCPR's purpose is to enhance the quality ol patient care- 
sen ices through improved knowledge that can he used to meet 
society's health care needs. The Agency seek-, to achieve its 
mission through several broad goaU: di promoting improve- 
ments m clinical practice ami patient outcomes through more 
appropriate and effective health care services, (2) promoting 
improvement-- in the financing, organization, and delivery of 
health care services, and ( 3 1 increasing access to quality care. 

In addition, AHCPR is responsible for facilitating the de- 
velopment, review, and updating ol clinical practice guide- 
lines tor prevention, diagnosis, treatment, and management 
of conditions and clinical circumstances. The guideline de- 
velopment methodology emphasizes a comprehensive evalu- 
ation for empirical evidence, significant outcomes (including 
those important to patients), benefits and harms. Explicit 
documentation of methods, rationales, and assumptions is 
provided. Each guideline actually contains several parts: the 
technical guideline report, clinical practice guideline, quick 
reference guide lor clinicians, and a patient/parents guide. 
Differences in practice by gender are included in all docu- 
ments as warranted. The Agency lor Health Care Policy and 
Research Reauthorization Act ol 1992 explicitly includes 
prevention in the clinical guidelines program objectives. 

M 1CPR acquires, develops, anil transfers new knowledge 
through a coordinated program of research, demonstrations, 
evaluations, and information dissemination activities. \1 [CPR 
also sponsors individual and insliiutioii.il National Research 
Service Awards, which provide pre- and post-doctoral support 
tor academic training and for research concerning health ser- 
vices research methods and problems. AHCPR also sponsors 
conferences on primary care research. 

AHCPR Prevention Highlights 

AHCPR has been addressing a broad range of issues identi- 
fied in HEALTH) PEOPLE 2000. including the availability of 
qualified minority health professional researchers. 

.Medical Treatment Effectiveness Program (MEDTEP) 
Research Centers on Minority Populations. This .AHCPR 
grants program provides assistance to minority health students 
and schools and supports health services research that ad- 
dresses barriers to use, determinants of differential morbidity 
and mortality, institutional and programmatic influences, and 
cost-benefit/cost-effectiveness analysis of programs. Grants 
have been awarded to the following groups: 

• Harlem Urban Health Research Institute, to study vari- 
ations in treatment and outcomes for heart disease, hy- 
pertension, .AIDS, and tuberculosis, and prevention of 
childhood injury among inner-city African Americans; 



• 1 lavv.ui Asian Pacific Island MEDTEP Research Center, 
to examine community interventions to reduce the inci- 
dence ofpulmonarj tuberculosis, as well as the effective- 
ness of cancer treatment, type 11 diabetes, and asthma 
among Asian and Pacific Islanders; 

• Morehouse Medical Treatment Effectiveness Center, to 
examine prenatal care, heart disease, hypertension, 

Ml >S. and end-stage renal disease in African Americans; 

• UCLA/MEDTEP Center for Asians and Pacific- 
Islanders, to address geriatric issues and assess varia- 
tions and outcomes ol breast cancer treatment among 
Asian Americans, including the psychosocial aspects of 
treatment; 

• Mexican American Effectiveness Research Center, to 
siudv functional status in the elderly, ami variations and 
outcomes ot treatment tor diabetes, substance abuse, 
and depression among Mexican Americans; 

• New Mexico MEDTEP Research Center on Minority 
Populations, to assess the effectiveness of mammogra- 
phy screening and the outcomes of tj pe 11 diabetes ther- 
apy among American Indians. 

• five additional MEDTEP Research Centers were 
recently established at the University of California at San 
Francisco, University ol Illinois, Henry Ford Hospital, 
Meharry Medical Center, and the University of Maryland. 

Institute on Minority Capacity Building in Health Ser- 
vices Research. \l 1CPR organized this institute to familiar- 
ize participants wnh AHCPR's current research; to provide 

technical assistance in areas such as study design and statistical 
techniques; and to establish relationships between facuhv and 
potential researchers in this area. 

\ selection ot projects currently funded by AHCPR indi- 
cates a continuing emphasis on research related to clinical 
practice activities in prevention, especially rural and minority 
health promotion, and disease prevention activities and 
services. The AHCPR has also established, in cooperation 
with the Centers tor Disease Control and Prevention, a panel 
ot private-sector health care experts and consumers to de- 
velop clinical practice guidelines for smoking prevention and 
noil. 

Caregiving lor Minority Women With AIDS. The purpose 
of this exploratory study is to describe caregiving patterns to 
generate new hypotheses on caregiving needs, community' as- 
sistance, and gaps in sen ices lor minority women with AIDS. 
Minority women from a State-designated AIDS clinic will be 
interviewed and assigned to an interdisciplinary team includ- 
ing a psychiatrist, a medical specialist in AIDS, a nutritionist, 
and a case manager. 

Evaluating RACE (Reducing AIDS Thru Community 
Education). This dissertation grant is aimed at evaluating 
the efficacy of a national AIDS education program targeting 
black church congregations and determining its potential for 
replication in other locations. A secondary analysis of data 
collected from focus group transcripts and surveys of 1,054 
church members will be conducted to develop a descriptive 
analysis of the population reached through the project. The 
project expects to determine the effectiveness of churches in 
disseminating AIDS information in African American 
communities. 



Agency Innovations 



Multilevel Practice Model for Rural Hispanics. This pro- 
ject evaluates the success of a three-tiered community-based 
nursing delivery model in a Mexican American rural commu- 
nity, and uses quasi-experimental research design with mea- 
sures of process, outcome, and impact. The demonstration 
component will develop and implement three nursing inter- 
ventions: personal preventive nursing, organized indigenous 
caregiving, and community empowerment. The focus of both 
the model and the interventions is on improving the health of 
the population by directing the interventions to individuals 
and lamilies, groups, and the community. 

Dissemination of Prevention Guidelines to Harlem 
Physicians. Designed to develop a model for training of med- 
ical/primary care residents and attending physicians, the study 
will evaluate the impact of educational intervention on physi- 
cians' preventive health behaviors, attitudes, and practices in a 
large inner city hospital. The research methodology uses se- 
lected U.S. Preventive Services Task Force clinical practice 
guidelines to stimulate health promotion and disease preven- 
tion activities among practicing physicians and their patients. 

WIC Breastfeeding Promotion — A Randomized Trial. The 

effectiveness of several interventions on starting and continuing 
breast ieeding among low income women will be studied. 
Women from rural areas are randomized to receive either spe- 
cial WIC breast feeding counseling and reinforcement during 
regular WIC prenatal visits, or routine WIC] prenatal visits or 
routine registration. After deliver}', women will be randomized 
to receive either a non-formula discharge pack or a routine dis- 
charge pack which includes bottled formula. The results may 
lead to generalizable conclusions about barriers to and methods 
for increasing breast feeding in low income, rural populations. 

Improving the Health of Medicaid-Eligible Infants. This 
pilot study tests the feasibility of combined home- and office- 
based interventions to improve utilization of care and health 
outcomes of Medicaid-eligible infants. Participants are 120 
Medicaid-eligible pregnant women and their babies, and 4 pe- 
diatric practices in a 3-county area in North Carolina. They 
are randomly assigned to different interventions, which are 
expected to facilitate continuous and coordinated care. This 
pilot will determine if the interventions should be evaluated in 
a randomized trial in several North Carolina communities. 

Primary Care for High-Risk Indigent Infants. This experi- 
ment tests an intervention of providing higher intensity post- 
discharge care to high-risk, low-birth-weight infants. The ob- 
jectives are to reduce infant mortality, morbidity, and need for 
intensive care in the early months following delivery. It will be 
implemented in a hospital with a sizable proportion of such 
infants from low-income families. 

State Medicaid Policies for AIDS-Related Health Care. 

The Medicaid program in each State is being surveyed by mail 
to collect data on the reimbursement and coverage of AIDS- 
related hospital services, nursing home care, home health and 
hospice care, physician services and prescription drug cover- 
age. The data from these surveys will be used as a catalog of 
current iMedicaid reimbursement, coverage and eligibility 
policies for health services provided to Medicaid recipients 
with MDS. 



The Effects of Rural Obstetric Care Provider Shortages. 

This population-based cohort study addresses whether 
women residing in rural areas with shortages of obstetric 
providers are: (1) more likely to delay the receipt of prenatal 
care than other women; (2) receive adequate prenatal care; 
(3) more likely to experience adverse pregnancy outcomes 
such as low birth weight, neonatal mortality, and perinatal 
mortality. The study uses data from a statewide assessment 
of obstetric care provider availability, vital records, and ma- 
ternal Medicaid enrollment. A nested case control study 
using data from a statewide Perinatal Risk Factor Surveil- 
lance Program will explore the influence of obstetric 
providers and maternal residence on the recognized risk fac- 
tors associated with adverse perinatal outcome such as ma- 
ternal lifestyle, medical risk factors and complications of 
labor and delivery. 

Influencing Obstetric Care for Minority, Poor, and Rural 
Women. The primary focus of the study is to investigate the 
hypothesis that there is variation in the care pregnant women 
receive based on ethnicity, Medicaid status, and the location of 
the provider. The study uses previously collected data which in- 
cludes all providers of obstetrical services including hospital de- 
liveries in Washington State. Criteria for patient selection were: 
entered prenatal care during first trimester; between 18 and 34 
years of age; and had no previous important medical problems. 
The study will contribute to our knowledge of the prenatal care 
received by minority and Medicaid-eligible women. 

Patient Notification and Follow-up of Abnormal Mam- 
mograms. This retrospective cohort study of 1,000 women 
with abnormal screening mammograms is designed to deter- 
mine the magnitude of the problem of inadequate follow-up. 
Problems with notifying patients will be identified. Among 
women advised to have follow-up, risk factors for noncompli- 
ance will be determined through interviews. Questions elicit 
information about potential barriers to compliance as well as 
health beliefs and health behaviors, thus contributing clues 
about ways to improve health services delivery. 

Guidelines for HrV Screening. The project collects finan- 
cial data from a VA Hospital, a large HMO, and an ambula- 
tory academic practice, in addition to published data, to de- 
velop an HIV screening guideline applicable to the general 
population. The importance of selected variables, and the 
benefits of knowing the differences in these variables, will be 
used in estimating the cost-effectiveness of using the guideline 
for screening. 

Lifestyle and Diabetic Amputation in Pima Indians. This 
retrospective case-control study examines the relationship be- 
tween amputations in diabetic Pima Indians and related clini- 
cal, demographic, and lifestyle factors. Using existing IHS 
medical records, first lower extremity amputations for adult 
diabetic Pima or Tohono O'odham Indians on the Gila River 
reservation are compared to diabetic controls without amputa- 
tion for the period 1985 to 1992. Logistic regression is being- 
used to estimate odds ratios for amputation. A methodologic 
study on the feasibility of developing a diabetes registry from 
automated IHS clinic data is also being performed. The find- 
ings should be beneficial for the prevention of complications 
of diabetes. 



© 



Prevention '93/94: Federal Programs and Progress 



&k 



\ Comparison of S/HMO and TEFRA HMO Enrollees. 

This study is designed to compare the cost and use of health 
care services and health and functional status measures lor en- 
rollees in a Social 1 le.ilth Maintenance Organization (S 1 l\IOt 
with those enrollees in .1 TEFR Wisk Mev.lie.ire 1 IMC ). I lover- 
age is identical except for the S HMO's long-term care and 
e.ise management sendees. Cost and utilization data will he col- 
lected tor two observational periods: the year prior to the col- 
lection of the mailed survey data, and the year following the 
mailed survey. Relationships between cost, utilization, .\nA 
health/functional status (as outcome measures* will he exam- 
ined using the pre-survev utilization and cost data. The find- 
ings will evaluate this innovative approach to organizing, fi- 
nancing, and delivering health care sen ices which attempts to 
control resource use while proriding high quality cue. 

Diffusion and Adoption of Children's Vaccine Guide- 
lines. In a nationally representative sample of pei.liatnci.uis. 
family physicians, and general practitioners, this study will 
identify the physician's awareness of children's vaccines guide- 
lines, document actual compliance with these guidelines, and 
delineate the possible harriers to implementation. 

Implementations of Guidelines in a Large Group-Prac- 
tice I l\K). I'his stud) evaluates strategies for implementing 

clinical practice guidelines and the effect of guidelines on the 
delivery of primary care in large group practices. The study 
randomizes 250 primary care physicians in mi I lAlO to one of 
four arms (academic detailing, continuous qualit) improve- 
ment, both, or neither) .uu\ then evaluates the effects on the 
implementation ol clinical guidelines tor hypertension and de- 
pression. Outcomes measured are changes in patient blood 
pressure, scores on a depression instrument (Beck Depression 
Inventory), and costs ol care. Provider knowledge and satisfac- 
tion are also surveyed. The design will permit testing ol inter- 
actions between clinical practice guidelines and implementa- 
tion interventions. 

Retention of Physicians in ( onimunitv I lealth Ccntei s 
survey of physicians — current and previous — in community 

and migrant health centers is being conducted to determine 
factors associated with retention of primary care physicians. 
The findings are expected to address issues related to effective 

recruitment and retention. 

Migrant Farm Workers' Health Needs and Vccess to Ser- 
vice. Health conditions, utilization patterns, and unmet needs 
ot migrant farm workers in Wisconsin are being compared to 
determine whether self-perceived health needs, harriers to 
care, and medical utilization changed between 1978 and 1989. 
Analyses are underway to test hypotheses related to the pro- 
portions ot migrants, by education, age, and income, who per- 
ceive their health as fair or poor; who state they have never 
seen a dentist: who report chronic illness such as hyperten- 
sion, diabetes, and arthritis: and use State vouchers tor pay- 
ment ot provider services. 

Physical Health and Medical Care in a Homeless Cohort. 

This study defines and determines the predictors ot the nat- 
ural course of physical health status, health services utilization, 
and self-reported compliance with prescribed treatment 
anions; a community cohort of homeless adults. It will he 



linked with an ongoing National Institute of Mental Health 
studv which focuses on demographic, social, ami mental 
health characteristics surrounding intervals of homelessness. 
This studv is testing the hypothesis that as persons vv ith one or 
more of the monitored conditions exit or reduce homeless- 
ness, their medical conditions vv ill improve in 6 months, they 
more than likely obtain outpatient medical care, they will more 
than likely comply vvith prescribed medical therapy, and will 
less likely have hospital care during a 12-month period. 

Health Insurance for the Low Income: An 1- valuation. 
This project evaluates the impact of the State of Washington's 
Basic 1 lealth Plan (BHP) on access to care. B11P is a State- 
subsidized voluntary health insurance plan for low-income 
and uninsured persons, with emphasis on preventive care. Ser- 
vices are provided by managed health care systems under con- 
tract to the State. The findings can provide policymakers with 
information about programmatic issues critical to the success 
State-subsidized insurance approach. 

Strategies tor Management ol Dental Caries in Children. 

This studv examines the effect that early intervention with 
dental sealants versus later intervention with restorative den- 
tisin has on patient outcomes. Three separate seis ol anal) ses 
will he conducted using 1983 1990 data lor approximately 

I "0,(Klll North Carolina Medicaid dental users 5 17 years of 
age. These findings will assist in providing a rationale for 
sealant reimbursement policy. 

Resident Physician Practice Style and Patient Outcomes. 
At the University ot California Davis, 5()( ) nonpregnant new 

adult patients will he randomized to receive primary care 
through either the family medicine or internal medicine clinic. 
Baseline information will he collected and the visit with the 
resident physician videotaped for evaluation using the Davis 
Observational Code. Two additional visits will he taped over 
the study year. Evaluations of functional status, patient satisfac- 
tion, and physiological parameters are being collected at base- 
line and at the end of the year. The study will document the re- 
lationship between physician practice style and outcome and 
will he useful in the future training ol primarj cue physicians. 

Practice-Based Research on Low Back Pain in Primary 

( are. The studv is to he conducted in both the United States 
and the U.K. via practice-based research networks. The data 
gathered will include demographic, occupational, compensa- 
tion, and clinical characteristics; patterns ol diagnostic evalua- 
tion anil therapies received from all sources and their per- 
ceived effectiveness; and patient utilization of health care 
resources for hack problems within 2 months of initial presen- 
tation and outcomes at 1 months. The studv addresses the 
need tor descriptive information on low hack pain in the con- 
text of rehabilitation and disability compensation, creates a 
data set for secondary analysis, and serves as a pilot tor a larger 
international study in primary care networks. 

Measuring Effectiveness of Clinical Management Sys- 
tems. Measures ot performance will be developed tor 12 clin- 
ical management systems in the areas of provision of care, 
completion of workups, implementation of treatment deci- 
sions, implementation of preventive care, and communication 
with patients. The study will be implemented at four sites in 



Agency Innovations 



two major ambulatory health care systems. Error rates and 
patterns of errors between plan data and patient reported data 
will be ascertained and used to construct performance rates 
which will be combined into a profile of performance scores 
for feedback to the plans. It is expected that patient-based in- 
formation will be less intrusive and expensive to obtain than 
health plan data and that it can be used to develop valid indi- 
cators of overall system performance. 



Agency for Toxic 
Substances and 
Disease Registry 
(atsdr) 

The Agency for Toxic Substances and Disease Registiy 
(ATSDR) was created in 1980 as a separate entity of the Pub- 
lic Health Service (PHS) by the Comprehensive Environmen- 
tal Response, Compensation, and Liability Act (CERCLA), or 
what is more commonly known as Superfund. The mission of 
ATSDR is to prevent or mitigate adverse human health effects 
and diminished quality ot life resulting from exposure to haz- 
ardous substances in the environment. ATSDR determines 
the links between human exposure to hazardous substances 
and any increased incidence of adverse health effects by apply- 
ing state-of-the-art scientific methods, creating and building 
relevant data bases, and identifying appropriate target popula- 
tions for investigation. ATSDR has responsibility to (1) detect 
the presence and assess the nature of health hazards at Super- 
fund sites, (2) help prevent or reduce further human exposure 
to hazardous substances and diseases resulting from such ex- 
posures, and (3) expand and communicate the scientific- 
knowledge base about health effects resulting from exposure 
to hazardous substances. ATSDR is also responsible for the 
tracking and implementation of 4 of the 16 environmental 
health objectives of HEALTHY PEOPLE 2000 and is a partici- 
pant on the work group tracking all of the environmental 
health chapter objectives. 

ATSDR Prevention Highlights 

Health Assessments. ATSDR perforins public health assess- 
ments of all sites proposed for or listed on the National Prior- 
ities List, and in response to petitions for health assessments 
received from the public. A public health assessment is an in- 
tegrated evaluation of environmental contamination data, 
community health concerns, and health outcome data. The 
purposes of the public health assessment are to (1) identify 
hazards posed by hazardous waste sites and (2) identify af- 
fected communities, including persons living and working 
near these sites, for whom public health actions are necessary. 
During the period October 1, 1991, through September 30, 
1992, ATSDR, in collaboration with 21 State health depart- 
ments, completed 233 public health assessments, including 19 
petitioned health assessments. 



Toxicological Profiles. ATSDR develops profiles on the tox- 
icological characteristics of the ATSDR/EPA Superfund Pri- 
ority Hazardous Substances. ATSDR has developed 145 pro- 
files for 209 of the 275 Priority Hazardous Substances. These 
documents are used domestically and internationally to com- 
municate substance-specific information and are used by 
health professions while conducting public health assessments 
and evaluations. The total number of profiles distributed since 
1987 is estimated to exceed 1 million. ATSDR now distributes 
final profiles free of charge to approximately 2,100 recipients 
at Federal, State, and local public health agencies, academia 
(libraries and departments in toxicology or related fields), and 
nonprofit organizations. 

Great Lakes Human Health Effects Research Program. 

During FY 1992, ATSDR announced a $2 million grant pro- 
gram to conduct research on the human health impact of fish 
consumption in the Great Lakes region under the Great Lakes 
Critical Programs Act of 1990. ATSDR announced nine 
awards under this program. Research undertaken through this 
program will build upon and amplify the results from past and 
ongoing fish consumption research in the Great Lakes Basin. 
Information gained from these efforts can then be related to 
national human health research efforts and be used to develop 
data bases, and research methodologies that will provide long- 
term benefits to the Great Lakes human health research ef- 
fort. This applied research effort will provide information to 
State and local health departments for use in refining fish con- 
sumption advisories, medical practice, and public education. 
Additionally, research from this program will provide infor- 
mation to address specific data needs for priority hazardous 
substances identified by ATSDR. 

Priority Health Conditions. ATSDR has developed a list of 
priority health conditions to (1) help define health conditions 
that should be considered most important during evaluation 
of populations living near hazardous waste sites; and (2) iden- 
tify areas for research in assessing the association between ex- 
posures to hazardous substances and adverse health outcomes. 
The priority health conditions were selected based on the fre- 
quency of occurrence of adverse human health conditions as- 
sociated with the most hazardous substances at hazardous 
waste sites, the severity of the adverse human health condi- 
tions, the frequency or extent of concern expressed to physi- 
cians and other public health practitioners by persons living 
near hazardous waste sites, and the ability to effect the illness 
through prevention activities or medical care. The ATSDR 
priority health conditions, in alphabetical order, are (1) birth 
defects and reproductive disorders, (2) cancer of selected 
anatomic sites, (3) immune function disorders, (4) kidney dys- 
function, (5) liver dysfunction, (6) lung and respiratory dis- 
eases, and (7) neurotoxic disorders. Six studies have been initi- 
ated in State health department and State-based universities 
focusing on lung and respiratory diseases and birth defects and 
reproductive disorders. 

Health Studies. ATSDR completed seven studies that pro- 
vided information about the biological uptake of hazardous 
substances in humans. Four of the studies emphasized evalua- 
tions of the manner, or pathways, of exposure. Soil was the 
pathway of exposure for studies of heavy metals, volatile or- 
ganic chemicals, and polychlorinated biphenyls (PCBs). Two 



Prevention '93/'94: Federal Programs and Progress 



© 



studies of populations living in areas contaminated bj 
from mining activities were completed. 1 he results ol the 
study ol residents ot Aspen, Colorado, living near the Smug- 
gler Mountain Superfund site, are ot considerable interest. Al- 
though the blood lead concentrations among children were 
\erv low, the study was important in that the exposure find- 
ings conflicted with previously developed models that had 
predicted higher blood lead levels. These findings have initi- 
ated additional environmental and biological studies about the 
bioavailability of lead in varying States. Another stud) evalu- 
ated exposures to pesticides from the consumption ot contam- 
inated fish. The consumption ot pesticide-contaminated food, 
such as fish, is an important problem because of the stability 1 
and bioaccumulation ot some pesticides. The study demon- 
strated that the consumers of fish from contaminated areas 
were nearly 5 times more likely to have elevated serum levels 
ot a metabolite ot the pesticide chlordane, a suspected car- 
cinogenic substance. 

National Exposure Registry. The ATSDR National Expo- 
sure Registry is comprised ot chemical-specific subregistries 
designed to aid in assessing the long-term health conse- 
quences ot low-level, long-term exposures to hazardous chem- 
icals identified at hazardous waste sites. The goals ot the Na- 
tional Exposure Registry are to facilitate epidemiolo 
research, to facilitate State and Federal health surveillance 
ins, and to provide current relevant information to ex- 
posed persons. Mso. registries serve an important role in en- 
suring the uniformity and quality of collected data across dif- 
ferent sites. Four hazardous substances have been selected for 
the chemical-specific subregistries that currentlv make up the 
National Evposure Registry: ill rxichloroethylent 
dioxin. (3) benzene, ami i4) chromium. Participation In com- 
munity residents in an exposure subregistn is voluntary. Re- 
sponse rates lor the subregistries developed bv VI SDI\ have 
been very high, averaging more than 97-percent participation 
bv exposed people. VTSDR routinely informs registrants ol 
new developments related to chemicals ol concern. 

Health Education. In 1990, ATSDR began developing a sc- 
ries of monographs entitled Case Studies in Environmental Med- 
icine to inform health care professionals of health effects 
caused by hazardous substances in the environment. 1 hese 
self-instructional exercises in environmental medicine are de- 
signed to guide primary care practitioners in the diagnosis, 
treatment, and surveillance ot disease among people exposed 
to hazardous substances in the environment. Seventeen of the 
monographs in the series are now in print, with 16 more in 
production. In FY 1992, ATSDR distributed over 100,000 
copies ot the monographs to health care professionals 
throughout the United States. Nearly 1,800 health profession- 
als received either continuing medical education or continuing 
education unit credit for their participation in the case studies 
program. 

Minority Health Program. ATSDR has established a con- 
solidated ATSDR Minority Health Prosr.mi to ( 1 l determine 
and continue to define the extent to which minority popula- 
tions bear a disproportionate burden of illness and injury as 
caused by exposure to hazardous waste and releases into the 
environment; (2) design and implement specific health and 
risk communication strategies for minority populations; i 1 



design and implement public health interventions and pro- 
grams that (a) define and respond to the particular needs ol 
minority populations. m\A [U) evaluate and address differences 
among cultural and ethnic groups; and (4) continue collabora 
tive efforts with acadeinia to increase the number of minorities 
trained in the environineiu.il health sciences. 



Centers for Disease 
Control and 
Prevention (cdc) 



The Centers tor Disease Control and Prevention's vision 
for the future is of "healthy people in a healthy world." I be 
mission ot CDC is to promote health anil quality of life bv 
preventing and controlling disease, injury, ami disability. \s 
the Nation's prevention agency, CDC accomplishes its mis- 
sion bv working with partners throughout the Nation and the 
world to: 

• monitor health 

• detect ami investigate health problems 

• conduct research to enhance prevention 

• develop and advocate sound public health policies 

• implement prevention strategies 

• promote healthy behaviors, and 

• foster sale .mA healthful environments 

CDC smves to achieve national preventi bjectives bv 

coordinating surveillance, data collection and analysis, epi- 
demiologic investigations, and laboratory research; by serving 
as national and international reference laboratories; by provid- 
ing technical assistance, grants, and cooperative agreements to 
Stale ami local health departments; and by collaborating with 
partners in academic institutions, volunteer and professional 
organizations, medical care settings, philanthropic founda- 
tions, and business and labor groups. 



The National Immunization 
Program (nip) 

The National Immunization Program was established in 
Alav 1993 to provide national leadership for planning, coordi- 
nating, and conducting Federal, State, and local immunization 
activities. In carrying out this mission, the National Immu- 
nization Program il) assists State and local health depart- 
ments to develop and implement programs for the prevention, 
control, and eventual eradication ol diseases for which effec- 
tive immunizing agents are available; (2) supports the estab- 
lishment of vaccine supply contracts for vaccine distribution 
to State and local immunization programs; (3) assists States 
and local health departments in developing systems to identify 
children who need vaccinations, help parents and providers as- 
sure that all children are immunized at the appropriate age; as- 
sess immunization levels at State and local levels; and monitor 
the safety and efficacy of vaccines; (4) administers research and 
operational programs for the prevention and control of vac- 



Agency Innovations 



cine-preventable diseases; and (5) supports a nationwide 
framework for effective surveillance of designated diseases for 
which effective immunizing agents are available. 



National Center for Chronic 
Disease Prevention and Health 
Promotion (nccdphp) 

The National Center for Chronic Disease Prevention and 
Health Promotion is concerned with chronic diseases and 
conditions that can be prevented or mitigated by personal be- 
havior choices. NCCDPHP stresses the translation of re- 
search findings into effective community-based programs, 
strengthening the deliver)' of preventive health services, and 
designing programs to meet the needs of minority groups. 
NCCDPHP has assumed the lead role for CDC in coordinat- 
ing the tracking and implementing of the diabetes and chronic 
disabling conditions, educational and community-based pro- 
grams, and tobacco priority area objectives tor HEALTHY PEO- 
PLE 2000. 

NCCDPHP Prevention Highlights 

Preventive Health and Health Services (PHHS) Block 
Grant. Established in 1982, the PHHS Block Grant has been 
newly reauthorized and focuses on the achievement of the 
HEALTHY PEOPLE 2000 objectives, including provisions for 
States to create health plans, improved annual reporting of 
program activities, and targeting of public health interven- 
tions to populations in need. FY 1993 funding is S148.8 mil- 
lion. Eligible grantees are the 50 States, the District of Co- 
lumbia, the 8 U.S. Territories, the Kickapoo Tribe of Kansas, 
and the Santee Sioux Tribe of Nebraska. 

The Block Grant is the primary source of Federal funding to 
States for health education/risk reduction activities, cholesterol 
and hypertension screening, emergency medical sendees, and 
sex offenses prevention programs. It is also a leading source of 
funds to support laboratories, dental health/fluoridation pro- 
grams, environmental health activities, and rodent control pro- 
grams. The flexible provisions of the grant allow- States to ad- 
dress health problems and target populations most in need. 

National AIDS Information and Education Program 
(NAIEP). The National AIDS Information and Education 
Program, which became operational in mid- 1987, is responsi- 
ble for the national "America Responds to AIDS" (ART A) in- 
formation campaign, the CDC National AIDS Hotline, and 
the CDC National AIDS Clearinghouse. NAIEP provides as- 
sistance to national, regional, community-based, and minority 
organizations to build their capacity to deliver AIDS preven- 
tion programs. 

NAIEP is applying mass communication evaluation guide- 
lines recommended by the National Academy of Sciences and 
testing evaluation methods that have been used in the private 
sector. Phase VI of the ARTA campaign released in March 
1991 had the theme, "Americans Working Together to Pre- 
vent HIV and AIDS." The campaign has three objectives: (1) 
to increase the salience of HIV and AIDS as an important 
health issue in terms of an individual's risk and of the epi- 
demic's societal impact, (2) to increase the proportion of the 
population who appropriately adopt or maintain the behaviors 



that lower the risk of HIV infection, and (3) to increase the 
proportion of the population who appropriately seek HIV 
counseling, testing, and early intervention services. 

A cooperative agreement with the American Red Cross has 
developed a component of the campaign targeted to Hispanic 
populations that is receiving widespread acclaim as an out- 
standing example ol an adult-education, low-literacy informa- 
tion program. The program is being delivered in cooperation 
with the National Council of La Raza. The American Red 
Cross, through its national leadership and network of over 
2,800 chapters, continues its education efforts with (1) the 
general public, (2) the black community, in cooperation with 
the National Urban League, (3) business, labor, civic, and so- 
cial organizations, and (4) educational institutions. 

The national and regional minority organization program 
of CDC has awarded 32 grants to minority organizations in- 
volved in HIV prevention. Major progress has been made to 
promote understanding and positive involvement of churches 
and synagogues in HIV and AIDS prevention efforts. 

Through its business initiative, "Business Responds to 
AIDS," NAIEP works with public and private sector organiza- 
tions to stimulate greater participation of HIV/ AIDS preven- 
tion, information, and education efforts among national orga- 
nizations and institutions, including voluntary and service 
organizations, to develop and implement HIV information 
and education programs and to coordinate those efforts with 
national, State, and local public sector programs. At the Fed- 
eral level, NAIEP participates with other Federal agencies re- 
sponding to AIDS, including agencies within the Public 
Health Service and the Departments of Labor, Commerce, 
and Veterans Affairs, and the Small Business Administration. 

Prevention Centers Program. The goal of the Prevention 
Centers Research Program is to bridge gaps between scientific 
knowledge and public health practice. Seven academic-based 
centers work with State and local health departments and 
communities to rapidly transfer research results to improve 
health promotion and disease prevention efforts. 

Research activities in FY 1993 have focused on ethnic and 
minority populations, rural communities, worksites, and youth 
and older adults. For example, the Columbia University 
School of Public Health/Harlem Hospital Prevention Center 
was established to reduce excess mortality and morbidity in 
Harlem. The Lmiversitv of Washington Center for Health 
Promotion in Older Adults is working to identify modifiable 
risk factors affecting the leading causes of disability, illness 
and early death in older adults. 

Behavioral Risk Factor Surveillance System (BRFSS). 

NCCDPHP has provided resource assistance to 45 States and 
the District of Columbia to enable them to monitor the preva- 
lence of major behavioral risk factors associated with leading 
causes of premature death and disability in the United States. 
Monitoring is accomplished with telephone surveys using ran- 
dom-digit dialing and computer-assisted telephone interview- 
ing methodologies. States are using the data to develop 
statewide objectives for the reduction of these risks; monitor 
the impact of new legislation, such as mandatory seat belt use 
laws; and improve their prevention programs. 

Cardiovascular Health. CDC conducts surveillance and ap- 
plied epidemiologic research on cardiovascular disease and as- 



^Pb 



Prevention '93/'94: Federal Programs and Progress 



ed risk factors. A national coronary heart disease - 
lance report and a companion report on stroke surveillance 
help set priorities, target community intervention efforts, and 
monitor progress in preventing the most common can 
death in the United States. <■ 1 >( collaborates with States such 
as New York and Missouri to conduct and evaluate commu- 
nity-based intervention projects to prevent cardiovascular dis- 
ease. CDC works with the Indian Health Service to design, 
implement, and assess community-based interventions for 
American Indians in the Bemidji (.Minnesota) service area. 

Cancer Prevention and Control. ( lu collaborates with 
public health agencies, voluntary organizations, and other 
Federal agencies to develop activities designed to decrease 
morbidity and mortality from selected cancers. I -A 1993 ap- 
propriations oi >"2.^ million tor the "Breast and Cervical 
Cancer Mortality Prevention Act ol 1990" are enabling CDC 
to support the development and implementation ol breast and 
I cancer programs in 5(1 States. These programs benefit 
.ill women but specificalh target minorin and underserved 
women. CDC also guides national level activities in the areas 
ot provider education, public education, quality assurance ol 
mammography ami Pap tests, surveillance, ami evaluation. 
( 1 )( is collabi irating with other PUS agencies to implement 
a strategic plan to address issues pertinent to breast and cervi- 
cal cancer control. The National Institute on Child Health 
and I luman Development funded CDC to be the Data ( loor- 
dinating Center tor a population-based case-control studv to 
assess the relationship between the risk ot breast cancer .\m\ 
the prior use ol oral contraceptives among 10,000 women ages 
>5-64. 

Prenatal Smoking ( ess.uion il's( i Program. Smoking is a 
major cause ot low birth weight, anil is a leading contributor 
to infant mortality. One ol even tour women in the United 
States smokes during pregnancy and 2.s percent ot low-birth- 
weight births mav he attributed to smoking during pregnancy. 
The T s m's main goal is to reduce smoking during 

pregnancy by promoting integration of prenatal smokini 
sation counseling into routine prenatal care. In FY 1993, 
( 1 )( ' provided direct support to 12 State health departments 

in developing, implementing, and evaluating prenatal smoking 
cessation programs tor pregnant smokers who use public pre- 
natal clinics and Women. Infants, and Children i\\ IC) pro- 
gram clinics. In FY 1 ( '''4. CDC will locus resources in three 
major areas: 1 1 1 disseminating prenatal smoking cessation in- 
formation to health care providers through the development 
of a national prenatal smoking cessation data base. (2) Draining 
maternal and infant health care providers in prenatal ces 
counseling techniques, and (3) funding further evaluation ol 
intervention strategies tor pregnant smokers. 

Infant Health. CDC is helping Mates enhance their surveil- 
lance of behavioral risk factors and prevention practices re- 
lated to pregnancy and infant health through two surveillance 
systems: one surveys women who have recentlv given birth; 
the second involves expanding a surveillance system in 25 
States to collect information from high-risk pregnant women 
who participate in publicly funded prenatal care programs. 
CDC will initiate new research activities for examining the 
difference between black and white rates ot infant morbidity 
ami mortality. These include studies of (1) previously unrec- 



ed risk factors for preterm deliver) and (2) risk factors 
for post-neonatal mortality. CDC assists Slates in building 
their analytic capacity to use epidemiologic and surveillance 
data to address problems affecting women, infants, and chil- 
dren through short-term technical assistance, assignment of 
epidemiologists to Slate maternal and child health programs, 
and assistance in the development of State-based epidemiol- 
ogy centers. 

In recent years, there has been little or no improvement in 
the prevalence ot iron deficicncv anemia in women, especially 
during pregnancy. Iron deficiency has bun associated with 
adverse pregnancy outcomes, especially with pre-term births. 
Ibis problem continues in spile of the fact thai pregnant 
women are usi.allv prescribed prenatal iron supplements dur- 
ing pregnancy. CDC has initiated a pilot project to demon- 
strate the effectiveness of a targeted intervention program to 
reduce the high prevalence ol iron deficiency anemia among 
low-income pregnant women. 

Physical \ctivitv and Health. Physical activity has been 
demonstrated to be .\n important risk (actor for coronary heart 
disease and other chronic diseases. Given the large proportion 
of sedentary people in the United States, the potential health 
benefits of increased physical activity are great. CDC monitors 
physical activitv trends through the BRFSS. Workshops and 
ongoing discussions with leaders in trie scientific community 
are held to determine the public health message regarding 
physical activitv. Special projects assess determinants ol and 
barriers to physical activity in minorities, women, older adults. 
auA other underserved populations at risk. Community-based 
intervention projects attempt to increase physical activitv levels 
in poor, predominantly black communities. \ handbook lor 
promotion ol physical activitv by Si ate and local health depart- 
ments has been developed and will be widely disseminated. 

Adolescent and School Health Programs (AS] IP). CDC 
actively supports s4 State/Territorial and 17 local education 
departments and 23 national organizations to provide educa- 
tion in I 1IV risk reduction to youth. In FY 1993, CDC began 
lo support comprehensive school health program activities in 
the Arkansas. District of Columbia, Florida, and West Vir- 
ginia State education agencies. All received cooperative agree- 
ment funds to undertake three activities. First, a senior level 
staff person will be hired by both the Department of Health 
and the Department of Education. These individuals will be 
located within the Office of the Superintendent of Education 
and ( lommissioner of I [ealth and will work to improve the in- 
frastructure within both departments to promote comprehen- 
sive school health programs. Secondly, a Coordinator for 
( lomprehensive School 1 Icalth Programs will be placed within 
the Department of Education to direct programmatic efforts. 
Finally, school health efforts within the State will be expanded 
to include prevention ot tobacco use, sedentary lifestyle, and 
nutrition habits that result in chronic illness. In addition, 
CDC is working to develop guidelines tor school-based pro- 
grams tor nutrition, tor physical activity, and tor comprehen- 
sive school health education. 

The 1993 Youth Risk Behavior Survey (YRBS) was con- 
ducted by CDC at the national, State, and local levels to mon- 
itor the prevalence of health-risk behaviors among samples of 
school-aged youth. CDC also initiated plans to conduct the 
National School Health Studv, a survey of school policies and 



Agency Innovations 



programs that support comprehensive school health education 
in grades kindergarten through 12 th. The study will provide 
baseline data on 17 HEALTHY PEOPLE 2000 objectives and will 
be available in 1995. 

CDC has established a network of Comprehensive School 
Health Education Teacher Training Centers that train teach- 
ers to implement comprehensive school health education, in- 
cluding education to prevent HIV infection. In FY 1993, there 
were training centers in 40 States, with plans to establish a 
training center in every State. 

Community Recognition. The Secretary's Community 
Health Promotion Awards Program has recognized over 850 
local programs throughout the United States since 1983. In 
July 1993, the 1994 Awards Program began. All States and 
Territories are invited to participate. 

HIV Prevention in Women. By 1990, HIV/AIDS had be- 
come the sixth leading cause of death in women 25-44 years of 
age. The prevention of HIV infection in women is supported 
through a multisite project aimed at developing and evaluating 
clinic-based interventions among women at risk for HIV 7 in- 
fection. This project also aims to prevent HIV infection in in- 
fants by preventing unintended pregnancies among HIV-in- 
fected women. Project CARES (Comprehensive AIDS 
Reproductive Health and Education Study) sites use commu- 
nity outreach to recruit and refer women into family planning 
and HIV clinics, and offer family planning services in home- 
less shelters and drug treatment centers. 

CDC has collaborated with clinics (including family plan- 
ning clinics) to design and apply a service model to evaluate 
the integration of HIV education, counseling, and testing ser- 
vices into existing services for women. The goal is to provide 
guidance to clinic managers and suggest ways to improve 
these services for women in clinics. In FY 1993, CDC tested 
the service model in the 1 5 clinics in New York, Seattle, and 
San Francisco to document how well services have improved 
and been integrated into existing services for women. The 
study will be expanded to other types of clinics such as urban 
and rural family planning clinics. 

Health Education and Health Promotion Programs. CDC 

provides professional development, capacity building, and coor- 
dination with various organizations. The annual National 
Health Education and Health Promotion Conference, held in 
cooperation with the Association of State and Territorial Direc- 
tors of Public Health Education, provides the major source of 
continuing education for State-level public health education 
staff. CDC continues to coordinate and expand the use of the 
Planned Approach to Community Health (PATCH) by State 
and local health departments by training State PATCH coordi- 
nators in the methods and applications of this community plan- 
ning model. CDC is also developing the use of worksites as 
channels for health education and health promotion programs. 

Tobacco and Health. CDC conducts epidemiologic analyses 
of tobacco use and tobacco-related morbidity and mortality, 
monitors trends in tobacco control legislation and policy issues, 
provides technical assistance to States in planning and conduct- 
ing local tobacco control programs, conducts national public in- 
formation and education campaigns through the mass media, 
and maintains national data bases on tobacco and health. 



CDC produces the annual report of the Surgeon General 
on the health consequences of smoking. The next report, Pre- 
venting Tobacco Use Among Young People, focuses on the initia- 
tion of tobacco use among America's youth. 

In 1991 and 1992, CDC published a series of articles and 
special reports on young people's use of tobacco products 
based on data from the 1989 Teenage Attitudes and Practices 
Survey (TAPS). In 1994, CDC will issue the results of the 
1993 TAPS follow-up survey. 

In January 1993, CDC launched a national public education 
campaign to inform the general public, parents, and workers 
of the health risks posed by secondhand tobacco smoke. This 
campaign coincided with the release of a major risk assessment 
by the Environmental Protection Agency that classified sec- 
ondhand smoke as a known cause of cancer in humans. Also, 
CDC, in collaboration with the National Medical Association, 
released an advertising campaign targeting African Americans. 
Through a 1-800 number included in the advertisements, in- 
dividuals can request a culturally appropriate quitting guide. 

Diabetes. The goal of CDC's diabetes prevention and control 
program is to reduce the morbidity, premature mortality, and 
cost burdens resulting from diabetes and its complications. To 
achieve that goal, CDC provides financial assistance, pro- 
grammatic consultation, educational materials for health pro- 
fessionals and persons with diabetes, and guidance in commu- 
nity-based intervention planning to 26 States and 1 territory 
to implement State-based Diabetes Control Programs. CDC 
has also initiated a major demonstration project, Diabetes In- 
tervention Reaching and Educating Communities Together, 
which focuses on reducing the burden of diabetes in two 
North Carolina communities with large African American 
populations. The project, which is jointly supported by CDC 
and the Agency for Health Care Policy and Research 
(AHCPR), will apply both primary and tertiary interventions. 

Nutrition. In 1990, CDC produced and disseminated a man- 
ual entitled Nutrition Intervention in Chronic Disease: A Guide to 
Effective Programs that provides information on building part- 
nerships and developing specific interventions at the commu- 
nity level. A national satellite training program using this 
manual is planned for State and local agencies. CDC, along 
with other Federal agencies, provided support to the Associa- 
tion for State and Territorial Public Health Nutrition Direc- 
tors to devise specific strategies and tactics to achieve dietary 
change to prevent chronic disease. The process includes di- 
verse partners from industry, nonprofit and professional orga- 
nizations and the Federal Government. Four States collabo- 
rated with CDC in a worksite-based cholesterol reduction 
project. The project demonstrated reduced cholesterol levels 
following nutrition intervention. Harvard and Minnesota 
Schools of Public Health collaboration continued to investi- 
gate the long-term effects of voluntary weight loss. CDC col- 
laborated with Ohio's WIC program to improve the iron sta- 
tus of women through supplementation with a new low dose 
iron pill that will cause fewer side effects. The CDC and the 
Human Nutrition Center at the University of Texas School of 
Public Health are collaborating on a project to assist States to 
collect and use dietary data in a variety of settings. The assis- 
tance will consist of providing software and technical assis- 
tance in dietary assessment methods in community surveys 
and/or health services. 



^a 



Prevention '93 '94: Federal Programs and Progress 



Health Promotion for Older Adults. CDC focuses applied 
research and programmatic efforts on nmseuloskelet.il diseases 
isteoporosis), chronic neurological diseases 
(Alzheimer's disease, Parkinson's disease), urinary inconti- 
nence, and the development of measures of health status and 
quality of life. Musculoskeletal diseases are the most prevalent 
chronic diseases, affecting 57 million persons in the United 
States. A 3-vear study of osteoarthritis in Johnston Count) - , 
North Carolina, will determine the incidence, prevalence, and 
natural history of hip and knee osteoarthritis in a rural com- 
munity with a large black population. Osteoporosis surveil- 
lance and intervention demonstration projects are underway 
in X'eu Icrscv and Colorado. \ survey oi perimenopausal 
women in Atlanta will assess women's knowledge .uiA attitudes 
about hormonal replacement therapy. Other efforts include 
studies of the incidence, prevalence, and risk factors for 
Alzheimer's disease, a condition that affects 4 million people. 
and an ongoing projeel with the Indian Health Service to de- 
velop a model comprehensive health care program tor older 
American Indians. 

Unintended Pregnancy. Over one-third ol recent births in 
the United States have resulted from unintended pregnancies. 
< I >( is cng igc ' m activities to reduce the incidence o! unin- 
tended pregnancy. Using focus groups, factors that indicate 
how women and their partners chouse whether to use birth 
control and factors that affect the selection and effectiveness 
of specific methods were separatel) evaluated among white, 
black, and Hispanic women. Studies are planned in examine 
how life experiences, and other characteristics (i.e., employ- 
ment, education, marital st.mis. childbearing, l.unih relation- 
ships, behavior, and personality) influence the risk ol unin- 
tended pregnane)'. CDC "ill assist the Vrizona State Health 
Department in conducting a statewide reproductive health 
survey, which will oversample Hispanics. CDC is also working 
with Emory Universit) to identify determinants of unintended 
pregnancy using on a theoretical model developed from the 
psychosocial literature. 



© 



National Center for 
Environmental Health (nceh) 

The National Center lor Environmental Health strives to 
improve human health and quality ol lite by preventing envi- 
ronmental disease, birth detects, and disability. NCEH con- 
ducts programs designed to assist the public health commu- 
nity in the surveillance, investigation, analysis, prevention, and 
control ot environmentally induced health problems. NCEH 
has lead responsibility- within CDC tor the tracking and im- 
plementing of the environmental health priority area objec- 
tives for Healthy People 20 

NCEH Prevention Highlights 

Surveillance and Prevention of Birth Defects and Devel- 
opmental Disabilities. NCEH monitors the occurrence of 
over 1 50 rvpes ot birth detects through two major surveillance 
ispital discharge data: the Birth Defects .Moni- 
toring Program and the Metropolitan Atlanta Congenital De- 
fects Program. NCEH also provides support to State-based 



birth delects surveillance programs. N't !1'1 1 also conducts pop- 
ulation-based surveillance ot four major developmental disabil- 
ities using special education through the Metropolitan Atlanta 
Developmental Disabilities Surveillance Program. These pro- 
grams serve as a basis tor epidemiologic research CO find causes 
ot birth detects and developmental disabilities, to develop .uul 
evaluate prevention strategies, and to provide guidance on pro- 
gram development ami implementation to State and local 
health departments. NCEH current!) has projects to deter- 
mine the effectiveness of folic acid in preventing spina bifida, 
to determine the effectiveness of an intervention to prevent 
poverty-associated mental retardation, and to find and imple- 
ment effective prevention strategies tor fetal alcohol syndrome. 

Disabilities Prevention Program. The goal o! the program 
is to reduce the incidence ami sevcniv ot disabilities. The pro- 
gram expanded to 2S State-based capacity building projects in 
FY 1992, and continues in FY 1993 at that level. Il targets se- 
lected developmental disabilities, head and spinal cord in- 
juries, and secondary disabilities. It supports prevention em- 
phasis tor selected chronic conditions. In addition, five 
demonstration/epidemiology projects tor the prevention ol 
secondan conditions associated with cerebral palsy, tetal alco- 
hol svndrome, and health and spinal cord injuries were funded 
in 1A 1992. \s a result of findings from the Institute of Medi- 
cine report. Disability in America, and recommendations from 
the National Conference on Prevention of Primarv and Sec- 
ondan Disabilities, NCEH has started development of a Na- 
tional Plan for the Prevention of Disabilities. 

Detection and Measurement of Toxic and Hazardous 
Substances in Humans. NCEH is assessing exposure and 
health effects ol potential exposure to toxic substances that 
have widespread use and/or high toxicity, NCEH has devel- 
oped laboratory methods lor measuring dioxins, anil related 
compounds. }2 volatile organic compounds, 12 pesticide 
metabolites, 12 chlorinated hydrocarbon pesticides, and 25 
toxic elements in human blood and urine in the low parts per 
billion or trillion range. NCEH has developed batteries of lab- 
orator) measurements lor examining health effects to the kid- 
nev and liver resulting from exposure to hazardous substances. 
New projects include the application ol a new laboratory mea- 
sure ol exposure to lobacco products in blood in order to ob- 
tain national prevalence estimates of exposure to passive or en- 
vironmental tobacco smoke: the development of improved 
laboratory measurements of health effects to the immune sys- 
tem resulting from exposure to hazardous substances; and de- 
velopment ol a new instrument lor measuring blood lead. 

Environmental Public Health Programs. N'UHII deals with 
health problems associated with chemical toxicants such as 
pesticides, organochlorine compounds, and solvents; heavy 
metals: other inorganic substances; and radiation exposure and 
other energy-related issues. N( J-'I 1 also addresses health 
problems associated with the physical environment, including 
natural and technologic disasters and the health effects ol air 
pollution. NCEH is directing a long-term national program 
designed to eliminate childhood lead poisoning — the leading 
environmental disease among children in the United States. 
NCEH plays a leading role in international efforts to prevent 
the health effects of air pollution and other environmental 
conditions and works with State and local health agencies to 



Agency Innovations 



strengthen environmental disease prevention programs, such 
as asthma. In addition, NCEH coordinates national analytic 
epidemiologic research on radiation exposure and other en- 
ergy-related public health issues. 

Emergency Response. NCEH has developed a variety of ac- 
tivities to address health-related issues associated with techno- 
logical hazards and natural diseases. A 24-hour emergency 
number (404-488-7100) has been established to support re- 
sponse personnel on the State and local levels. NCEH will as- 
sist in planning and is also beginning specialized surveillance 
activities, improving computer capabilities for collecting and 
retrieving data, conducting descriptive and analytic epidemio- 
logic studies, and studying environmental exposure pathways. 

Special Programs Group. The Vessel Sanitation Program 
(VSP) continues as a cooperative activity with the cruise ship 
industry to maintain a level of sanitation on passenger vessels 
that will lower the risk of gastrointestinal disease outbreaks. A 
comprehensive sanitation program is monitored through a 
mandated inspection process, whose operating cost is fully re- 
covered through inspection fees. VSP redesigned its sanitation 
training seminars for shipboard management personnel. The 
VSP also conducts onsite construction reviews for new vessels 
and for renovations of existing vessels, which are designed to 
help shipbuilders integrate new disease prevention technolo- 
gies. NCEH continues to assist State and local health officials 
prepare communities near lethal chemical weapons stockpile 
locations in improving their medical emergency response ca- 
pabilities. The skills developed by health care professionals 
will not only be useful in the unlikely event of a catastrophic 
release of a chemical agent, but will help the community de- 
velop a more generalized ability to prevent casualties during 
emergencies involving hazardous materials and to better han- 
dle those casualties that do occur. 



National Center for Injury 
Prevention and Control (ncipc) 

On June 25, 1992, the National Center for Injury Preven- 
tion and Control (NCIPC) was formed. NCIPC runs a com- 
prehensive national program to control intentional and unin- 
tentional injuries, the leading cause of death for persons ages 
1 — 14 and the leading cause of years of potential life lost. The 
program (1) leads and coordinates national injury control ef- 
forts, (2) establishes surveillance for injuries, (3) conducts and 
supports research, and (4) supports State and local health de- 
partments in building capacity' for injury surveillance and im- 
plementing interventions to control injuries. The national 
program encompasses the prevention of nonoccupational in- 
juries, and applied research and evaluations in acute care and 
rehabilitation of injured persons. NCIPC addresses injury 
prevention and control through research on (1) causes, cir- 
cumstances, and risk factors and (2) interventions and their 
impact on defined populations. 

NCIPC supports eight multi-disciplinary injury control re- 
search centers in academic institutions. NCIPC also sponsors 
27 research projects to determine the cause of injuries, iden- 
tify interventions, or evaluate the effect of an intervention. In 
addition, over 20 grants to State and local health departments 



provide capacity and support surveillance and interventions to 
make and chart progress in controlling injuries. Research and 
intervention efforts are beginning to make a difference. Re- 
searchers at the Harborview Injury Control Center, supported 
by CDC, have shown that wearing a helmet reduces the risk of 
head injury by 85 percent in bicycle crashes. The widespread 
application of these and other interventions should reduce the 
toll of injuries on our society. NCIPC has the lead responsi- 
bility within CDC for tracking and implementing the violent 
and abusive behavior and unintentional injuries priority areas 
for Healthy People 2000. 

NCIPC Prevention Highlights 

Injury Control — What Works. This was the theme of The 
Second World Conference on Injury Control held in Atlanta, 
iVIay 1993. Hosted by CDC and co-sponsored by 10 other na- 
tional and international organizations involved in injury con- 
trol, the conference focused on worldwide progress in injury 
research and the practical approaches to injury prevention and 
control. The conference program included over 800 presenta- 
tions with about 1 ,400 attendees from 60 different countries. 

Youth Suicide Prevention Programs: A Resource Guide. The 

resource guide describes the rationale and effectiveness of var- 
ious youth suicide prevention strategies and identifies model 
programs. Building on the outcome of the 1990 Forum on 
Youth Violence in Minority Communities, The Prevention of 
Youth Violence: A Framework for Community Action is designed 
to help communities develop potentially successful violence 
prevention programs based on the best available knowledge. It 
includes rationales for different approaches to youth violence 
prevention and examples of current programs. 

Extramural Grants. In 1993, NCIPC awarded the first two 
cooperative agreements to support demonstration projects to 
prevent youth violence and awarded the first grant for a train- 
ing and demonstration center in acute care. Grants totaling 
$13 million were awarded for research in the three phases of 
injury control: prevention, acute care, and rehabilitation, and 
the two major disciplines of injury control: epidemiology and 
biomechanics. Approximately $6 million in grants were pro- 
vided to State and local health departments and community- 
based organizations to implement and evaluate interventions 
to prevent injuries. 

Injuries Caused by Firearms. Cooperative agreements with 
States to conduct population-based surveillance in two prior- 
ity areas: head injuries (including evaluation of E-codes) and 
firearm injuries. NCIPC continued an interagency agreement 
with the Consumer Product Safety Commission to use the 
National Electronic Injury Surveillance System to obtain na- 
tional estimates of nonfatal firearm injuries, and associated 
risk factors, morbidity, cost, and long-term disability. 

Fall Injury Prevention. NCIPC supports a research grant to 
survey aspects of fall injuries among residents of two large se- 
nior housing centers, a nursing home, and among patients 
with hip fracture admitted to a major hospital. 

Drowning Prevention. Programs in California, Florida, 
Texas, and Washington focus on pool barriers and isolation 



Prevention 9 3 / ' 9 4 : Federal Programs and Progress 



© 



fencing ordinances to reduce the risk of drowning in swim- 
ming pools, particularly among small children. Education, 
marine safet) training, and public awareness campaigns are 
being conducted in California, Florida. Texas, Washington, 
Alaska, North Carolina, and Hawaii. In Alaska, approximately 
10.000 people have been trained in marine safety and survival, 
and an evaluation of the program has documented 21 lives 
saved. In 1 lawaii, an evaluation of different educational meth- 
ods showed instructional messages ai specific sues wert 
rive alternatives to public campaigns. 

["raffle-Related Injun Prevention. Collaborative t 
with the National Highway Traffic Safet) Vdministration 
(XHTSA) have resulted in MMli R reports on alcohol-related 
motor vehicle fatalities, child restraint use. and safer) belt use. 
While NHTSA's Fatal Occident Reporting System (FARS) 
h.is been key in studying t.it.il traffic crashes, no such system 
exists tor nonfatal traffic crashes. NCIPC is working on .i link- 
stem ot existing data to develop information on nonfatal 
crashes. NCIPC has also developed with NTITSA questions 
related to risk of vehicular injury for the Behavioral Risk Fac- 
tor Surveillance System (BRI ^ s 

Head Injun Prevention. I mhi; death certificates and emer- 
gency departmem data. CDC researchers found that bicycling 

accounted for 2,985 head injur) death-. ,)nd 905,752 head m- 
juries from 1984 to 1988. \n estimated 2,500 deaths and 
757,000 head injuries could have been prevented bv universal 
helmet use. In State-- with partial or no motorcycle helmet use 
laws, rates of deaths from head injury were almost twice those 
in States with comprehensive use laws. 

An evaluation ol the effectiveness ol bicycle helmet laws and 
education in Howard County, Maryland, showed an increase 
ot helmet use from 4 percent to 4" percent. Programs in 12 
States and New York (atv promote the use o( bicycle helmets 
through legislation, education ol children and parents, public 
education, sponsored events such as bicycle rodeos, discount 
coupons for helmets, or giveaways. Programs in California 
anil Rhode Island actively promoted legislation to require hel- 
met use among motorcyclists. 

Focusing the grants on a small set ol areas will contribute to 
the development of a comprehensive national program and 
allow tor population-based evaluation ot various intervention 
strategies. To support this effort. NCIPC i-- developing rec- 
ommendations on intervention strategies. The first recom- 
mendation, now being developed, is on bicycle helmets. 

Violence Prevention. Injuries from violence can be self-in- 
flicted or interpersonal, including homicide and assault. 
spouse abuse, sexual assault, child abuse and neglect, and elder 
abuse. 

Suicide Studies. Risk factors tor suicide attempts in persons 
aged 13-34 are: exposure to another person's suicide or at- 
tempt, mobility or migration, and patterns of alcohol use. 
NCIPC assists the New Mexico Department of Health in 
evaluating the effect ot suicide prevention curriculum on sui- 
cidal ideation or behavior. Another study is investigating the 
correlation of rates of suicidal ideation and behavior and the 
behavior ot patients with panic disorders. A third studv con- 
ducted in Shelby Count)', Tennessee, and King Countv, 
Washington, assessed the association between firearms and 



suicide. Suicide victims were more likely than controls to have 
lived alone, taken prescribed psychotropic medication, been 
arrested, abused drugs or alcohol, or not graduated from high 
school. After controlling lor these characteristics, the presence 
ot a gun in the home was associated with an increased risk of 
suicide. 

Homicide Surveillance Summary. Compiled from the 
analysis of NCI IS mortality data and the FBI Uniform Crime 
Reports data, the study showed a marked increase in the rate 
ot homicide among voting black males, an increase almost en- 
tuelv due to homicides committed with firearms. Programs in 
California, New York City, Rhode Island, Florida, Maryland, 
Noith Carolina, and Kansas City target youth violence 
through a number of interventions, including conflict resolu- 
tion education, mass media campaigns, community Organiza- 
tion, mediation programs, and crisis intervention. 

Child Vbuse Surveillance. The information from this studv 
will be used to develop new data collection systems to identify 
and track sentinel events. In Missouri. NCIPC supports the 
development of data collection instruments and the training of 
teams that are required by law to investigate suspicious injury 
deaths ol children ihrouuli ace 15. 



National Center for Infectious 
Diseases (ncid) 

The mission ol the National Center for Infectious Diseases 
is to prevent unnecessary infectious disease morbidity and 
mortality through surveillance, applied research, and services. 
\( II) conducts a national program to improve the identifica- 
tion, investigation, diagnosis, prevention, ami control ofinfec- 
tious diseases, including the evaluation ot candidate vaccines 
ot public health importance. NCID provides, on the basis ol 
unmet national needs, laboratory diagnostic services to State 
health departments. It also provides tor the transfer of new di- 
agnostic technologies to the public anil private sectors. NCID 
has co-lead responsibilities lor CDC, with the National Cen- 
ter for Prevention Sen ices, in tracking and implementing the 
immunization and infectious diseases priority area objectives 
for Healthi People 2000. 

NCID Prevention Highlights 

Acquired Immunodeficiency Syndrome (AIDS). NCID 

conducts surveillance, epidemiologic, and laboratory-based 
investigations designed to monitor the epidemic of human im- 
munodeficiency v irus (1 1IV) infection and AIDS and to assess 
risk factors lor transmission. Specific surveillance activities in- 
clude (1) providing financial support and technical consulta- 
tion to State and local health departments lor standardized re- 
porting ol cases ol AIDS and ot HIV infection in States with 
this type of reporting; (2) conducting standardized HIV sero- 
prevalence surveys of designated subgroups of the U.S. popu- 
lation, including persons at increased risk and more general 
populations; (3) investigating unusual case reports of HIV in- 
fection and MDS in accordance with CDC guidelines and 
recommendations; (4) investigating cases of occupational!)' 
transmitted HIV infection; (5) conducting studies to deter- 
mine the spectrum of disease in HIV-infected men, women, 



Agency Innovations 



and children; and (6) designing, implementing, maintaining, 
and providing computer support of active surveillance pro- 
grams for HIV infection and AIDS at State and local levels 
and reporting collected data in surveillance reports. 

Epidemiologic activities include studies on behavioral and 
biologic factors involved in transmission of HIV, studies on 
the natural history of HIV disease in all populations, and the 
development of prevention guidelines. Laboratory investiga- 
tions include developing and evaluating new diagnostic tests 
for HIV infection, including serologic and viral isolation tech- 
niques for HIV-1 and HIV-2; initiating studies to more 
clearly define HIV biologic structures and functions that may 
be susceptible to drug intervention or vaccine development; 
and developing new technology tools for molecular epidemi- 
ology, such as those used to determine genetic relatedness be- 
tween HIV strains. Information from these studies has been 
essential for projecting future trends in AIDS cases; targeting 
prevention programs at national, State, and local levels for 
persons determined to be at increased risk for infection, in- 
cluding health care workers; and estimating the impact of the 
HIV epidemic in terms of its economic, social, and medical 
consequences. Based on information obtained through these 
studies, in 1992 NCID published a revised classification sys- 
tem for HIV infection and expanded surveillance case defini- 
tion for AIDS and a document describing projections of the 
number of persons diagnosed with AIDS and die number of 
immunosuppressed HIV-infected persons in the United States 
through 1994. 

Child Care. In the absence of a comprehensive prevention 
and control program, the incidence of child care related infec- 
tions and injuries is expected to increase significantly as more 
children attend these facilities. CDC's goals are to (1) prevent 
and control infectious diseases and injuries [acquired in]... 
child care [settings] by developing strategies that will address 
major risk factors identified through surveillance and epidemi- 
ologic studies; (2) evaluate the impact and cost-effectiveness of 
selected prevention and control measures through use of 
demonstration sites; (3) develop prevention and control guide- 
lines for health promotion and education materials targeted to 
child-care directors and staff, health providers, public health 
officials, parents, and children; and (4) work with State and 
local health departments to implement these activities. 

Foodborne Disease. Foodborne diseases annuallv cause at 
least 6 million illnesses in the United States. To develop pre- 
vention and intervention strategies, NCID is working to iden- 
tify the nature and extent of foodborne disease, the popula- 
tions at greatest risk, and behaviors that increase risk. NCID is 
working with State and local health departments to increase 
their ability to control and prevent foodborne diseases. NCID 
activities include (1) developing an active surveillance system, 
(2) developing new laboratory techniques for identifying food- 
borne pathogens and methods for detecting toxicants, (3) eval- 
uating existing prevention and intervention strategies, (4) de- 
signing food- and disease-specific control measures, (5) and 
developing prevention education materials. 

Hepatitis B. Perinatal transmission of hepatitis B virus 
(HBV) results in a high rate of infection, and 90 percent of in- 
fants infected at birth become chronically infected with HBV. 
As adults, thev are at high risk of death from hepatocellular 



carcinoma. More than 90 percent of these infections can be 
prevented if HBV-positive mothers are identified and their in- 
fants receive hepatitis B vaccine and hepatitis B immunize 
globulin soon after birth. Interruption of HBV transmission 
during early childhood is also important because of the high 
risk of chronic infection during the first 5 years of life. Immu- 
nization with hepatitis B vaccine is the most effective means of 
preventing HBV infection and its consequences. In the 
United States, the majority of acute cases of hepatitis B occur 
in adults, but the targeting of high-risk adults for selective im- 
munization has had limited impact on the incidence of disease. 
The most effective strategy would be immunization before 
persons engage in high-risk activities or behaviors. In Novem- 
ber 1991, the PHS Advisory Committee on Immunization 
Practices recommended a comprehensive strategy to eliminate 
transmission of hepatitis B in the United States which includes 
(1) prenatal testing of pregnant women to prevent perinatal 
HBV infections, (2) routine vaccination of all infants, (3) vac- 
cination of certain adolescents, and (4) vaccination of adults at 
high risk of infection. 

CDC currently funds perinatal HBV prevention programs 
in State immunization projects that provide for the estimated 
2.1 million women who receive prenatal care in the public sec- 
tor. In 1992, CDC began phased-implementation of routine 
infant hepatitis B immunization. Approximately 43 percent of 
the children served by public sector immunization programs 
were reached in FY 1993. CDC develops and distributes mul- 
timedia training and health education materials targeted at 
both providers and the public. 

Lyme Disease. Lyme disease is a potentially serious and de- 
bilitating infection that may lead to subacute and chronic 
complications affecting the joints, peripheral and central ner- 
vous system, heart, skin, and eyes. NCID's goal is to reduce 
the incidence of Lyme disease by identifying risk factors asso- 
ciated with transmission and developing improved prevention 
strategies, including education materials. To identify risk fac- 
tors, NCID is carrying out detailed epidemiologic and eco- 
logic studies in hvperendemic areas of the Northeast. NCID is 
establishing an international reference center for Lyme dis- 
ease and developing both a standardized national surveillance 
system and standardized serologic testing to support the sys- 
tem. NCID is also investigating effective tick control methods 
and possible vaccine development. 

Diarrhea in Infants. Each year in the United States about 
350 to 500 children die of preventable complications of diar- 
rheal illnesses including dehydration, electrolyte imbalance, 
and cardiac arrest. These deaths may represent 10 percent of 
the preventable, post-neonatal infant mortality in this coun- 
try. NCID is examining risk factors associated with diarrhea- 
related infant death by analyzing computer records of multiple 
causes of death and, based on this information, is planning in- 
vestigations to provide information for use in developing spe- 
cific intervention strategies to reduce such deaths. 

Hospital Infections. Approximately 2 million nosocomial in- 
fections occur in acute-care facilities annually, affecting an esti- 
mated 5 percent of all hospitalized patients. Recent analysis of 
data reported to NCID's National Nosocomial Infections Sur- 
veillance System demonstrated a 20-fold increase in bacterial 
infections that are resistant to one major antibiotic, possibly re- 



Prevention '93/'94: Federal Programs and Progress 



© 



sistant to all available antibiotics. Measures to prevent antibiotic 
resistance advocated by NCID for all hospitals include more 
consistent application of infection-control precautions and 
stronger recommendations tor appropriate use of antibiotics. 

Malaria. Approximately 1.000 imported malaria infections are 
reported each year in the I S. and several million American 
travelers arc exposed to potentially Fatal malaria. During 

1992, 44 U.S. citizens died of malaria. NCID activities 
include 1 1 ) the development and dissemination of malaria pre- 

:i sjuidelines tor American travelers and consultation 
with clinicians on the treatment of malaria. i2> collaboration 
with national ministries of health in the development ot im- 
proved control and prevention strategies, particularly in 
Africa. (3) collaboration uith AID and Will") in the develop- 
ment and testing of candidate malaria vaccines, and (4) con- 
duct of molecular genetic studies of the malaria mosquito vec- 
tor', of Unci to develop improved malaria control methods. 

Pneumococcal Disease. Pneumococcal infections cause ap- 
proximately 41). (Kit) deaths annually in the United State-- and 
have an even greater impact in developing countries, causing 
an estimated I million deaths annuallv among children under 
5 vears old. Pneumococcal infections will become more diffi- 
cult to manage cffcctivel\ as strains resistant to multiple an- 
timicrobial agents become more prevalent. N'CID is conduct- 
ing national surveillance lor invasive pneumococcal infections. 
Data from surveillance is being used to asses-, the ctlicacv ol 
the currently available pneumococcal vaccine, to make recom- 
mendations tor the development ot a protein-conjugate vac- 
cine, and to monitor the spread ot drug-resistant strains in the 
U.S. Outbreak investigations have provided the opportunity 
t" assess transmission of drug-resistani pneumococci within 
day care centers in Ohio, Vlaska, Kentucky, and rennessee. 
To develop strategies tor prevention til infection with drug- 
int strains in developing countries. N'CID is evaluating 
the spread ot drui_ r -rcsist.mt pneumococci m Egypt and Pak- 
istan. A manual has been prepared lor use by health programs 
in developing countries to survev lor antimicrobial resistance. 
N T CID is assessing the impact of a statewide campaign to ad- 
minister pneumococcal vaccine to all high-risk adults in 
1 lavvaii. N'CID has identified a pneumococcal cell wall protein 
that appears to he useful as an antigen and that produces a 
protective immune response in mice. Its potential as a vaccine- 
candidate will be explored. 

Influenza. Persons 65 vears ot age and older are at increased 
risk ..I complications from influenza. Data from past epi- 
demics show that a severe influenza epidemic may cause up to 
200.000 excess hospitalizations and more than 40,000 excess 
deaths. Inactivated influenza vaccines and the appropru 
ot antiviral medication are the current focus ol prevention and 
control efforts. These ettorts are greatly aided bv die national 
influenza surveillance tor viruses and influenza-associated 
morbidity and mortality that is conducted each influenza sea- 
son by NCID. Vaccine performance may be suboptimal unless 
vaccine contains the most current virus strains. NCID is 
working to improve its international influenza surveillance 
systems to provide an earlv warning tor the emergence and 
spread ot new influenza variants, and thereby, the essential 
data for determining the optimal composition of influenza 
vaccine each vear. 



National Center for Prevention 
Services (ncps) 

The National Center for Prevention Services plans, directs, 
and coordinates national programs to assist Stale and local 
health agencies in carrying out their responsibilities for pre- 
ventive health services. NCPS provides financial and technical 
assistance to aid State ami local health departments in estab- 
lishing and maintaining prevention and control programs di- 
rected toward such health problems as tuberculosis, sexually 
transmitted diseases. \1I)S. and poor oral health. It also ad- 
ministers a national quarantine program to protect against the 
introduction of diseases from other countries and conducts re- 
search to evaluate and improve the application ol current 
technology to the prevention ol disease. NCPS has lead re- 
sponsibility within CDC tor tracking and implementing the 
Se.xuallv Transmitted Diseases and Oral Health priority areas 
for 111 \l i in Pi OPl i 2000. 

NCPS Prevention Highlights 

Tuberculosis. From 1985 to 1992, the number of reported 

persons with tuberculosis in the United Stales increased, re 
versing the stead) decline of the last three decades. Final re- 
ported tuberculosis cases totaled 26,673 in 1992, a 1.5-percent 
increase from the previous vear. 

I uberculosis is concentrated in identifiable areas and popu 
lations that are amenable to intensified prevention and control 
ettorts. The Strategic Plan lor the Elimination ol Tuberculo- 
sis from the United States proposes more effective use ol ex- 
isting technology, development of new technology, and rapid 
transfer of technology to the field. In FY 1993, 66 State and 
local health departments received tuberculosis prevention and 
control cooperative agreements, which totaled approximately 
S34.3 million. These funds supported local programs, includ- 
ing the hiring ol local outreach workers to provide one-on- 
one management (directly observed therapy) for tuberculosis 
patients who would otherwise have to he hospitalized to cure 
their disease and to prevent these persons from transmitting 
their disease in the community. The patient management con- 
ducted in 1993 resulted in estimated savings of about $100 
million in hospitalization costs. 

In 1992, the federal Task Force published the National, lo- 
tion Plan to Combat Multi-drug Rcs/sh/ut Tuberculosis. During 
FY 1993, approximately $39.3 million of emergent-)' funds 
were awarded to 1 3 State and local health departments report- 
ing the largest number of persons with tuberculosis. These 
funds enhance their efforts in preventing and controlling 
multi-drug-resistant tuberculosis and support the implemen- 
tation ol model tuberculosis programs to demonstrate the ef- 
fectiveness and feasibility of new intervention strategies. 

Sexually Transmitted Diseases (STDs). Each year over 12 
million cases of STDs threaten the health of Americans. Apart 
from AIDS and subsequent death, the most serious complica- 
tions are pelvic inflammatory disease (PID), infertility, ectopic- 
pregnane)-, and cancer associated with human papillomavirus. 
Pregnant women with untreated STDs risk fetal and infant 
death, deliver) of a premature or low-birth-weight infant, or a 
newborn with birth defects, infant pneumonia, conjunctivitis, 
or a mental retardation. 



Agency Innovations 



More than 750,000 cases of PID are diagnosed and treated 
each year, resulting in more than 165,000 hospitalizations for 
women aged 15-44. PID is secondary to either chlamydia or 
gonococcal infection, and accounts for more than 125,000 
cases of tubal infertility and more than 60,000 cases of poten- 
tially fatal ectopic pregnancy. 

A new program, die Sexually Transmitted Diseases Acceler- 
ated Prevention Campaigns, was developed in 1992 and 1993. 
It will closely examine effective STD prevention programs, 
and develop innovative approaches that link programmatic, 
clinical, laboratory, epidemiological, and behavioral activities, 
both within and outside STD clinic-based programs. 

The Region X collaborative chlamydia testing program in 
family planning and STD clinics, funded through an intera- 
gency agreement with the Office of Population Affairs, suc- 
ceeded in reducing chlamydia prevalence in 165 family plan- 
ning clinics in Washington, Idaho, Oregon, and Alaska by over 
50 percent from 1988 to 1992. In 1993, this program was ex- 
panded to three additional PHS regions (III, VII, and VIII), 
and eventually will be implemented nationwide. Approximately 
4.8 million women and 459,000 men were tested for chlamy- 
dial infection in the United States last year, vvidi overall posi- 
tive rates of 7.7 percent for women and 12.9 percent for men. 

In 1992, disease intervention activities resulted in the pre- 
vention of an estimated 13,500 syphilis infections, 61,600 
gonorrhea infections, and 83,100 chlamydial infections. The 
estimated cost savings to the United States for these preven- 
tion activities ranged from approximately $210 million to 
$600 million. 

Human Immunodeficiency Virus (HIV)- As of June 1993, 
CDC had received reports of more than 305,000 AIDS cases 
and more than 200,000 deaths. An estimated 1 to 1.5 million 
Americans are infected with HIV. In the absence of a curative 
therapy or preventive vaccine, the goal of CDC's AIDS con- 
trol strategy is to reduce HIV transmission by influencing the 
behavior of people who are either HIV-infected or at high risk 
for infection. Delivery of health education/risk reduction mes- 
sages and HIV counseling and testing help infected individu- 
als adopt behaviors that prevent them from spreading the virus 
and reduce adverse psychological reactions, and help unin- 
fected individuals remain virus free. Spouses and sexual part- 
ners of HTV-seropositive individuals are also provided assis- 
tance to keep them free of infection; and HIV-infected people 
are now offered early medical interventions. Counseling and 
testing sites provided almost 2.7 million HIV antibody tests, 
of which more than 55,000 were antibody-positive in 1992. 
Additional efforts are designed to reach the general public 
with timely and accurate information that allays unjustified 
fears, facilitates rational behavior toward all aspects of the 
HIV epidemic, and promotes constructive support for the 
control efforts of public health officials. NCPS implements 
this strategy through cooperative agreements with State and 
local governments, national and regional organizations, and 
community-based organizations. 

Oral Health. NCPS continues to be a national focus for the 
control and prevention of oral diseases and conditions such as 
dental caries, oral cancer, and infectious diseases in the dental 
setting. NCPS provides consultation, training, and technical 
services to assist State and local governments and professional, 
educational, civic, and service organizations in planning, im- 



plementing, monitoring, and evaluating oral disease preven- 
tion and control programs. In addition, NCPS collaborates on 
projects to improve patient management and care within die 
dental care environment, including education of dental health 
care workers about infection control and tuberculosis control 
practices; assisting with development of infection control and 
tuberculosis control guidelines for use by dental schools; as- 
sisting States in investigating instances in which HIV-infected 
dental providers have continued to practice; and assessing the 
frequency, nature, and circumstances of percutaneous injuries 
among dentists. 

Refugee Health. Most of the approximately 130,000 refugees 
who enter the United States annually come from areas of high 
disease incidence. Refugee health assessment grant programs 
in 44 States and the District of Columbia report that approxi- 
mately 80 percent of refugees receive a general health assess- 
ment soon after arriving in the United States to detect health 
problems of public and personal health significance. CDC's 
continuing development of prevention programs in refugee 
health ultimately will contribute to a worldwide, standardized 
refugee screening, documentation, and notification system. 



National Center for Health 
Statistics (nchs) 

The National Center for Health Statistics is the principal 
Federal source of data used in planning health services and 
other programs that meet the health needs of the Nation. 
NCHS collects and analyzes data that address the full spec- 
trum of concerns in the health field, including overall health 
status, lifestyle, and exposure to unhealthful influences; the 
onset and diagnosis of illness and disability; and the use of 
health care and rehabilitation services. Data are released 
through NCHS publications, public-use data tapes, and jour- 
nal articles. CDC has delegated lead responsibility for most of 
die objectives in the Surveillance and Data Systems priority 
area to NCHS. One of NCHS's major tasks include monitor- 
ing progress toward the national objectives; NCHS's data 
bases provide tracking information for about 40 percent of 
Healthy People 2000 objectives and over 90 percent of the 
special population targets. 

NCHS Prevention Highlights 

National Health Interview Survey (NHIS). The annual Na- 
tional Health Interview Survey is a major source of data for 
tracking progress on selected 1990 and year 2000 health objec- 
tives. The topics addressed by the 1985,' 1990, and 1991 NHIS 
were high blood pressure control, pregnancy and infant health, 
occupational safety and health, injury control, dental health, 
smoking and health, misuse of alcohol, nutrition, physical fit- 
ness and exercise, and control of stress. The 1991 NHIS also in- 
cluded immunization and infectious diseases, heart disease and 
stroke, other chronic and disabling conditions, clinical and pre- 
ventive services, and mental health. Data on HIV knowledge 
and attitudes have been collected annually since August 1987. 
The 1992 NHIS included a Youth Risk Behavior Survey and 
repeated the comprehensive set of questions on cancer risk fac- 
tors first asked on the 1987 NHIS. A short health promotion 
questionnaire will be included annually through the year 2000. 



Prevention '93/94: Federal Programs and Progress 



National Vital Statistics System (NVSS). I lu National 
\"ital Statistics System is responsible tor the Nation's official 

vital statistics. The vital statistics arc produced through State- 
operated registration systems. Information provided includes 
extensive data on births and deaths. The Linked Birth and In- 
fant Death Data Set provides valuable information on infant 
mortality. The mortality data have recently been expanded to 
provide mure information on the Hispanic population. 

l l »SS National Maternal and Infant Health Surve) 
(N'.MIHS). This periodic survey collects information from 
three national samples of vital records: 10,000 certificates ot 
live birth; 4,000 reports of fetal death; and 6,000 death certifi- 
cates tor infants. About 60,000 mothers, hospitals where births 
and infant deaths occurred, and medical providers ot prenatal 
care were the target ol mailed follow-back questionnaires and 
interviews linked with sampled vital record--. The data will ta- 
cilitate research in the areas of low birth weight and infant and 
fetal death. In 1990, a longitudinal follow-up surve) of moth- 
ers from the 1988 Will IS was conducted. The next N.MIHS 
will be m 1994. 

National Health and Nutrition Examination Surve) 

(Nil \NI S). The 1"SN to 1994 Nil \NI s 111. ., nationally 
representative sample of persons, will provide detailed health 
historv information through interviews and physical examina- 
tions targeted to specific diseases ot current interest. I be tar- 
geted diseases in NHANES 111 include cardiovasculai 
ease, chronic obstructive pulmonarv disease, diabetes. 

gallbladder disease, kidney disease, arthritis, cancer, infec- 
tious diseases, allergies, depression, hearing loss, osteoporo- 
sis, dental caries, and periodontal disease. Nutritional status is 
assessed through dietary interviews, bioclieniic.il ami hemato- 
logical tests. .\nA both measurements. Release of data from 
the first wave of NHANES III I 1988-1991 i began in the fall 
of 1993. 

NllxNIS 1 Epidemiologic Follow-up Studv (N11IIS). 
This study is a nationwide follow-up of 14,4u~ persons who 
were 25-74 years old when first examined in NHANES I 
(1971-75). Periodic follow-ups (1982-84, 1986, 1987, 1992) 
of this cohort provide morbidity, mortality, and hospital and 
nursing home data. This studv was jointly initiated by the 
National Institute on \ging and NCI IS; other components 
ot NII1 and 1M1S subsequently joined in the planning and 
funding. 

National Surve) of lamilv Growth (NSFG). This multi- 
purpose survey ol women of childbearing age provides base- 
line and evaluation data for a variety of health promotion 
programs concerned with reproductive health, family plan- 
ning, maternal and child health. STDs. and IIIV. Interview- 
ing for the fourth cycle was conducted in 19XS. Analysis and 
publication of data from the 1988 NSFG (Cycle 4) and the 
subsequent re-interview of these women in 1990 continued in 
1991 and 1992. The 1994 NSFG will have a larger sample to 
provide better estimates lor minority women. 

National Ambulatory .Medical Care Survey (NAAICS). 

This survey is designed to provide national estimates of the 
volume and characteristics of office-based medical care. Hos- 
pital outpatient and emergency room visits were added in 



1992. Variables measured include patient demographics and 
complaints, physicians' diagnoses, and the ordering and pro 
visum ot diagnostic services, therapeutic services, consulta- 
tion services. .:nA medications. The surve) was conducted an- 
nually from l l, ~4 through 1981, in 1985, and annually since 
1989! 

National Hospital Discharge Survcv (NHDS), Ibis an- 
nual survey is the source of information on inpatient use of 

hospitals. NHDS includes data on expected source of pay- 
ment, length of slav. diagnosis, surgical procedures, and pat- 
terns ol use and care in hospitals. 

Other N( IIS Prevention Activities. NCHS coordinated 
the development of a set of health status indicators for Fed- 
eral, State, and local government use. These indicators were 
released in 1991. DATA 2000, a computerized inventor) of 
data sources for monitoring the national objectives, was re- 
leased m 1993. Research an the development ol survey in- 
struments to collect data related to the measurement ol years 
ol health) life continues, both w ithin N( 1 IS and w uh other 
researchers. In subsequent years, NCI IS will develop compa- 
rable data collection methodologies for use ai national, Slate. 
and local levels, and a national process will be developed io 
identify significant data gaps that limit our ability to measure 
progress toward the I li vi lin Peopli 2000 objectives. In ad- 
dition, NCHS will continue to work with State and local 
agencies to improve their ability to generate information 
needed to assess progress toward the objectives at State anil 
local levels. 



National Institute for 
Occupational Safety and 
Health (niosh) 

The National Institute for ( Iccupational Safety and I leahli's 
mission is to assure sale and healthful working conditions by 
providing the science needed to prevent occupational diseases 
and injuries. NIOSH conducts intramural research and sup- 
ports extramural research on occupational diseases and injuries; 
carries out, in response to requests, an average of 500 investi- 
gations in workplaces each year, evaluating all types ol health 
problems and hazards; and makes recommendations to the De- 
partment of Labor on emerging problems. NIOSH supports 
Educational Resource Centers in Occupational Safety and 
I lealth at 14 universities where professionals are trained in four 
core professional disciplines of the field — industrial hygiene, 
occupational medicine, occupational nursing, and safety — as 
well as individual training projects at about 30 other universi- 
ties and colleges. NIC )SI I is the lead agency responsible for re- 
porting on the achievement of the HEALTHY PEOPLE 2000 oc- 
cupational safety and health priority area objectives. 

NIOSH Prevention Highlights 

Surveillance. Surveillance systems are used lor the early de- 
tection and continuous assessment of the type and frequency 
of occupational disease, disability, and death; determining po- 
tential exposures to hazardous agents; and evaluating the ef- 
fectiveness of intervention efforts. NIOSH is improving exist- 



Agency Innovations 



ing surveillance systems and developing new approaches to 
identify trends in occupational diseases and injuries; the agri- 
culture and construction industries currently receive special 
emphasis. The Sentinel Event Notification System for Occu- 
pational Risks (SENSOR) is a network of designated health 
care providers operating through cooperative agreements be- 
tween NIOSH and participating State health departments. 
The NIOSH Fatality Assessment and Control Evaluation 
(FACE) project involves the investigation of selected types of 
work-related traumatic deaths. 

Since FY 1992, the NIOSH Alaska Activity has focused on 
the descriptive epidemiology of Alaskan industries, with a spe- 
cial emphasis on commercial fishing, which is the highest risk 
industry in the State. Project findings have provided justifica- 
tion for the development of a field station in Alaska to conduct 
research aimed at reducing work-related injuries and have 
been published in Public Health Reports. 

Research. Research continued to focus on specific recom- 
mendations from the National Strategies for the Prevention of 
Leading Work-Related Diseases and Injuries. The 10 leading dis- 
eases and injuries include occupational lung diseases, muscu- 
loskeletal injuries, occupational cancers, severe occupational 
traumatic injuries, occupational cardiovascular diseases, disor- 
ders of reproduction, neurotoxic disorders, noise-induced 
hearing loss, dermatological conditions, and psychological dis- 
orders. Since the original documentation, an 1 1th priority cat- 
egory, occupationally acquired infectious diseases, has been 
identified. 

On October 30, 1992, a groundbreaking ceremony for a 
new multimillion dollar state-of-the-art CDC/NIOSH re- 
search facility took place in Morgantown, West Virginia. The 
new advanced-technology laboratory will house new and in- 
novative research programs in occupational safety and health. 

Silicosis continues to plague American workers, with 634 
new cases of silicosis diagnosed between 1985 and 1990 in 
Michigan, New Jersey, Ohio, and Wisconsin alone. Silicosis 
may be prevented by identifying potentially exposed workers, 
high-risk occupations and worksites, and use of products con- 
taining silica, then making recommendations for intervention. 
To meet these needs, NIOSH is increasing efforts in promot- 
ing and performing health screening and surveillance as well 
as hazard surveillance. NIOSH is also working with the Occu- 
pational Safety and Health Administration (OSHA) and the 
Mine Safety and Health Administration (MSHA) to empha- 
size the importance of enforcing current standards and to de- 
velop new prevention and intervention strategies. Research to 
study dose-response relationships, especially the risk of low- 
exposure concentrations, continues. NIOSH is currently for- 
mulating a Silicosis Eradication Strategy that will focus on 
communication and education regarding silica exposure, 
screening and surveillance, and scientific research. 

NIOSH has accelerated research and training programs ad- 
dressing workplace stress. NIOSH stress research employs 
laboratory and field studies, including health hazard evalua- 
tions, to investigate improved methods for assessment of job 
stress, risk factors for job stress, health and performance ef- 
fects of job stress, and work redesign to prevent job stress. In 
November 1992, NIOSH and the American Psychological As- 
sociation (APA) convened the Scientific Conference on Job 
Stress, involving participants from 22 countries, to address 
"Stress in the 1990s: A Changing Work Force in a Changing 



Workplace." In FY 1993, NIOSH began working with the 
APA on a cooperative agreement to develop a post-doctoral 
training program in Occupational Health Psychology. Behav- 
ioral scientists will be trained in both psychology and occupa- 
tional health to provide the human resources needed by indus- 
try and labor to combat stress in the workplace. 

'in FY 1992, a joint CDC/ATSDR workshop, with repre- 
sentation from academia, Department of Energy (DOE) Na- 
tional Laboratories, unions, and community groups, identified 
energy-related health research needs at DOE facilities. As a 
result, a broad research agenda consisting of 19 projects was 
prepared. The ongoing program emphasizes studies at com- 
bined DOE sites and exposures other than ionizing radiation. 
Additionally, NIOSH and the National Center for Environ- 
mental Health (NCEH), CDC, awarded cooperative agree- 
ments to conduct an epidemiologic study to examine the asso- 
ciation between paternal ionizing radiation exposure and 
childhood leukemia in the workers' offspring as a follow-up to 
a British study. NIOSH is also studying mortality patterns 
among uranium enrichment workers at two DOE facilities. 
Onsite NIOSH observations were made at various locations, 
such as the Idaho National Engineering Laboratory, to learn 
about the operations and potential exposures to workers. 
NIOSH staff also reviewed the status and accomplishments of 
the continuing epidemiologic research program at several 
laboratories. 

NIOSH revised the second notice of proposed rulemaking 
to improve the testing and certification of industrial respira- 
tors. The proposed regulatory action will replace the existing 
certification tests and criteria now governed by 30 CFR Part 
1 1 with more effective and reliable performance testing under 
the new 42 CFR Part 84. The most significant changes to the 
first proposal include deletion of workplace testing require- 
ments, changes to the assigned protection factors, and addi- 
tional guidance in quality assurance requirements and on user 
information. 

Dissemination. NIOSH operates a toll-free number that 
provides information about the availability of health hazard 
evaluations (HHE) of workplaces. Under the Health Hazard 
Evaluation and Technical Assistance (HETA) Program, 
HHE requests related to the quality of the indoor environ- 
ment have increased and comprised nearly 40 percent of all 
HHE requests in 1992. Epidemiological studies have shown 
some evidence supporting a relationship between nonspecific 
symptoms and six workplace factors (air-conditioning sys- 
tems, presence of carpets, more workers in a space, ineffective 
cleaning of office space, use of photocopiers, and use of car- 
bonless paper). In addition, work organizational or psychoso- 
cial factors, gender, smoking, and history of allergies may also 
be important factors. NIOSH has worked closely with EPA 
to distribute a self-help guide to building owners and occu- 
pants. This guide makes specific recommendations on how to 
determine the likely causes of symptoms and offers an ap- 
proach to reduce the prevalence of these types of symptoms 
by improvements in ventilation systems and other actions. 
NIOSH is developing improved measurement techniques for 
both characterizing etiologic exposures and specific illness 
syndromes which will include new sampling and analysis 
techniques for microbiologic toxins, ventilation systems, and 
specific chemical exposures. Improved measures for the 
work-organization stressors and objective measures of poten- 



fflk 



Prevention '93 '94: Federal Programs and Progress 



ri.il health effects (i.e., clinical incisures of eye irritation or 
immune system activation) will he incorporated in future epi- 
demiologic studies. 

Training. The Occupational Safetv and Health Act requires 
that NIOSll maintain and improve the competence ol the oc- 
cupational safety and health professional and paraprofess 
work force. To meet this objective, NIOSH funds 14 Educa- 
tional Resource Centers which provide training for profes- 
sionals in occupational medicine, agricultural health and 
safety, occupational nursing, industrial hygiene, and safety for 
emergency response workers. NIOSll also funds 34 project 
training grants which develop occupational safety and health 
professionals in underserved geographic areas, predominantly 
black colleges, single discipline programs, physician assistants 
in occupational medicine, and other targeted groups. NIOSI 1 
has occupational health educational programs in four focus 
areas: occupational medicine (residency specialty in the 

schools of medicine); management development (academic 
and cooperative training in the schools of business); health 
professions training in the schools of engineering; and reha- 
bilitation and job reentry training in the \\ ork Performance 
Laboratory. The following training activities are being con- 
ducted: (l)a cooperative agreement with the International \- 
sociation of Fire fighters to provide occupational safety and 
health training tor emergency response workers; (2) a new ini- 
tiative in collaboration with the Educational Resource Centers 
to enhance industrial hygiene academic programs in the areas 
ot hazardous substances/hazardous waste management; (3 i the 
Accreditation Board lor Engineering and Technology study, 
with NIOSI 1 support, to update their data base regarding the 
occupational satctv and health content ot engineering aca- 
demic programs in the United States; (4) a new cooperative 
agreement with the Minerva Education Institute at Xavier 
University to create a nationwide faculty network to develop 
curriculum materials .\nd integrate them into the existing 
courses for educating students in the prevention of occupa- 
tional injuries anil illnesses; (5) continuing education to slid 
occupational safety and health professionals through Nl( >S| I 
courses; and (6) Educating Physicians in Occupational Health 
and the Environment (EPOCH-ENVI) workshops. A na- 
tional oversight/advisory committee representing preventive 
medicine, internal medicine, and family medicine was estab- 
lished to provide guidance to Project EPO( )H. 

Agriculture. For over a decade. NIOSll has been conduct- 
ing research on causes of injury and respiratory disease 
among agricultural workers. Since 1990, NIOSll has been 
developing a comprehensive national program for the pre- 
vention ot diseases and injuries among agricultural workers 
and their families. One component of this program is a con- 
certed effort to improve coordination between the many Fed- 
eral, State, voluntary, and private organizations concerned 
with agricultural safety and health. To carry out this effort, 
NIOSH (1) conducted an outreach program that targeted 
seven Future Farmers of America (FFA) chapters who were 
recognized for their excellence in community safety pro- 
grams; expansion of "Farm Safety 4-Just Kids"; and the 
NIOSH-funded Demonstration Cancer Control Projects 
that conducted community education about cancer risks from 
pesticides and sun exposure, and promoted early detection 
through the mass media, county fair display booths, and the 



4-1 1 and FFA; (2) conducted surveillance ot agriculture-re- 
lated disease and injur)' through the Occupational Health 
Nurses in Agricultural Communities Program in 50 rural 
communities in 10 States; (3) conducted the Agricultural 
1 lealth Promotion System cooperative agreement program in 
IS states which serves the agricultural worker by providing 
information dissemination, education, and referral services 
through the cooperative extension service network; (4) de- 
signed an agricultural surveillance training course to train on- 
site agricultural health and safety surveyors; (5) conducted a 
study to monitor real-time noise exposures because ot the sig- 
nificant hearing loss experienced by agricultural workers; (6) 
established two new Centers tor Occupational Health in 
Agriculture. There are now (\ Centers in the United States; 

(7) investigated scalping incidents in New York State and re- 
ported on the results of these investigations in the MMU'R; 

(8) developed a sampling anil analysis method for the simulta- 
neous determination ot l l > oiganophosphorus pesticides; and 

(9) assisted the American Society ol Agricultural Engineers in 
developing curriculum to he used in courses in engineering 
design and in agricultural satctv and health. 

( onstruction. NIOs] I is continuing to expand surveillance, 
research, and intervention activities to locus on the satctv and 
health of American construction workers. Construction trade 
workers have experienced excess rales ol cancer, asbestos-re- 
lated diseases, mental disorders, solvent-related disorders, 
tails, poisonings, industrial fatalities, anil homicides. They are 
also at risk lor occupational lung diseases, musculoskeletal dis- 
orders, hearing loss, and derinatological conditions Irom 
workplace exposure. NIOSll efforts related to construction 
s.iteiv and health include the following; (I) NIOSH provided 
( >SH \ with a critical review ol studies conducted on adverse 
effects of lead on fetal development and the adult cardiovascu- 
lar sv stem. Nli >sl I continued to investigate the effectiveness 
of current engineering control techniques used in reducing 
lead exposure among workers who remove lead-based paints, 
evaluated occupational exposures resulting from several lead 
removal techniques being pilot tested in housing units, and 
provided recommendations for use by the Department of 
Housing and Urban Development in developing final regula- 
tions for lead abatement contractors; (2) two NIOSH alerts 
were issued on preventing tails: Preventing Worker Injuries mid 
Deaths Caused by Falls from Suspension Scaffolds and Preventing 
Falls ami Electrocutions During Tree Trimming; (3) the NIOSH 
Slate .Model Construction Safety and 1 lealth Program trained 
thousands of construction workers; (4) studies of mortality 
patterns were conducted on data supplied by unions repre- 
senting carpenters, electrical workers, sheet metal workers, 
and bricklayers. Results ot these studies will be used to iden- 
tify and prevent construction-related disease and injury; and 
(5) a NIOSI I-funded study related to hazards in new con- 
struction and demolition has identified problems that are 
common, such as exposure to welding fumes, asbestos, asphalt 
fumes, noise, and musculoskeletal hazards resulting from 
overhead work and vibration. 

Occupational Transmission of Tuberculosis. The recent 
increase in tuberculosis (TB) cases is believed to be largely due 
to TB occurring in persons with HIV infection. Other groups 
at high risk for TB include workers in correctional facilities, 
shelters for the homeless, residential care facilities, nursing 



Agency Innovations 



homes, and hospitals, where the environment may be con- 
ducive to the airborne transmission of TB. In FY 1993, the 
NIOSH TB program conducted health hazard evaluations; 
epidemiologic evaluations of intervention programs that re- 
duce TB transmission; studied transmission of TB in workers 
in hospitals and correctional facilities; initiated development 
of a surveillance program for worker TB infection and disease; 
conducted research on engineering controls (ventilation and 
UV germicidal irradiation), respirators, and air sampling and 
analysis methods; developed educational materials for health 
care providers about TB infection control practices; and as- 
sisted the Department of Labor in producing a Joint Advisory 
Notice on occupational TB transmission. 

HIV and HBV. OSHA Regulation 29 CFR Part 1910.1030, 
entitled "Occupational Exposure to Bloodborne Pathogens," 
identifies the risks of hepatitis B to workers and requires em- 
ployers to pay for vaccinations. Other components to this 
strategy include surveillance to monitor disease incidence, 
both to establish the need for targeted programs and to assess 
program effectiveness, education programs for workers and 
employers, and technical assistance in preventive program 
management to employers, workers, and public health practi- 
tioners. Two primary considerations in this strategy are deter- 
mination of who is "at risk" and ensuring employer compli- 
ance. As a direct result of the publication of the Guidelines for 
Prevention of Transmission of Human Immunodeficiency Virus and 
Hepatitis B Virus to Health Care and Public Safety Workers and 
the companion document, A Curriculum Guide for Public Safety 
and Emergency Response Workers, NIOSH awarded a coopera- 
tive agreement to the United States Fire Administration to de- 
velop a course for the 2 million emergency response personnel 
who protect the public from the perils of fire, accidental in- 
jury, and sudden illness. 

Minority Health Programs. During FY 1992, NIOSH (1) 
provided training and educational grants to Meharry Medical 
College to support their Occupational Medicine Residency 
Program; St. Augustine's College to support their undergrad- 
uate Occupational Safety and Health Training Program; and 
the University of Puerto Rico to support their Occupational 
Health Training Program; (2) collaborated with the Minority 
Health Professions Foundation to support the need for mi- 
nority occupational health and safety research. Cooperative 
agreements were awarded to the Morehouse School of Medi- 
cine and the Charles R. Drew University of Medicine and 
Science; (3) conducted a variety of occupational safety and 
health programs through cooperative agreements with Agri- 
cultural Research Centers; (4) through the Center for Agri- 
cultural Research, Education and Disease at the University of 
California, Davis, targeted migrant and seasonal workers, 
particularly Hispanics. Outreach to Hispanic communities 
was conducted through radio stations and education of labor 
contractors; and (5) conducted research on breast cancer con- 
trol among female migrant farm laborers, Hispanics exposed 
to antimony, Hispanic contract workers at Los Alamos Na- 
tional Laboratory, and lung cancer among Navajo uranium 
miners. NIOSH has placed a high priority on improving sur- 
veillance for work-related injuries and fatalities involving 
Alaska Natives, and is developing intervention strategies tai- 
lored to the unique environmental and cultural conditions 
found in Alaska. 



Women's Health. According to the Bureau of Labor Statistics 
in 1991, women will comprise 47 percent of the work force by 
the year 2005. The 1988 National Health Interview Survey 
Occupational Health Supplement indicated that certain occu- 
pational injuries and illnesses may affect women differently 
from men. The scientific literature reports that women are also 
at higher risk for upper extremity musculoskeletal disorders. 
The National Traumatic Occupational Fatality data base 
showed that although males had higher fatality rates for all 
types of traumatic occupational injury, the proportion of injury 
deaths by homicide and suicide were higher for females. In FY 
1992, NIOSH research on occupational illnesses and injuries 
among female workers addressed occupational respiratory dis- 
ease, occupational cancers, musculoskeletal disorders, trau- 
matic injury and violence in the workplace, reproductive disor- 
ders, occupational cardiovascular diseases, job stress and 
psychological disorders, dermatological disorders, work-re- 
lated transmission of infectious diseases, agricultural safety and 
health, and other targeted research. NIOSH is also conducting 
a follow-up study to determine whether an association exists 
between video display terminal use and low birth weight or 
premature birth. In agricultural safety and health research, 
NIOSH recently conducted 43 programs in 25 States where 
research, surveillance, and intervention activities were targeted 
to female farmers and migrant workers. 



Epidemiology Program Office |epo) 

The Epidemiology Program Office serves as CDC's focal 
point for developing and applying innovative methods to epi- 
demiologic training, services, and communication. EPO also 
provides epidemiologic assistance through the assignment of 
staff for epidemiologic investigations; analysis of the influence 
of various factors on the incidence and severity of preventable 
health problems; and consultation to other CDC units, other 
Federal agencies, State and local health departments, interna- 
tional organizations, and other nations on public health sur- 
veillance and analytic methods. 

EPO manages the Epidemic Intelligence Service (EIS) pro- 
gram by recruiting, training, and assigning epidemiologists 
throughout CDC, in State and local health offices, and in in- 
ternational public health duty stations. EPO manages epidemi- 
ologic training programs in foreign countries, coordinates epi- 
demiological training abroad, and serves as a WHO 
Collaborating Center for Epidemiology Training. EPO plans, 
develops, edits, and produces the Morbidity and Mortality 
Weekly Report and related publications. EPO serves as the hub 
for a national system for collecting, analyzing, and communi- 
cating basic surveillance information, and a focal point for con- 
sultation in surveillance and analytic methods in public health. 

EPO Prevention Highlights 

Prevention Effectiveness. The EPO Prevention Effective- 
ness Activity coordinates the development of the conceptual 
framework for prevention effectiveness, coordinates the devel- 
opment of guidelines for assessing the effectiveness of preven- 
tion strategies, trains public health professionals in methods 
for assessing the effectiveness and economic impact of preven- 
tion strategies, and provides technical assistance throughout 
CDC for prevention-effectiveness studies. Prevention effec- 



Prevention '93/94: Federal Programs and Progress 



tiveness includes the identification of efficacious strategies to 
reduce morbidity and mortality and improve the quality ot 
life; the determination of the potential and practical impact ol 
those strategies (effectiveness), including their social, legal, 
ethical, and economic impacts; the determination ot optimal 
methods tor implementing those strategies; and the evaluation 
of the impact of prevention programs. EPO's 1993-94 pro- 
gram initiative focused on the difficult assessment problems 
that arise as a consequence of fiscal, ethical, or other con- 
straints, and provided the methods tor conducting assess- 
ments, the skills to conduct effectiveness studies and use the 
results, and mechanisms tor communicating the results. More 
specifically, EPO provided CDC staff ami State and local pub- 
lic health workers training in prevention effectiveness strate- 
gies, published and disseminated the framework lor assessing 
the effectiveness ot disease ami injury prevention, and devel- 
oped public health case studies on the practice and application 
nl prevention effectiveness methods. 

Preventive Medicine Residency. CDC's preventive medi- 
cine residency is a 2-year accredited program, fulfilling the el- 
igibility requirements ot the American Board ot Preventive 
.Medicine for the practicum phase of supervised training .mJ 

field experience. The program is designed to prepare phvsi- 
cians and veterinarians lor careers in general preventive medi- 
cine anil public health, wnh .1 special emphasis on epidemiol- 
ogy and community disease control. The residenc) also 
contributes to the professional development of physicians 
planning to enter careers in academic medicine, epidemiologic 
research, public health administration, community health, 
clinical preventive medicine, and international health. 

Public Health Surveillance. \,i 50 Vales. 2 large cities, and 
6 Territories electronically transmit weekly surveillance data 
for notifiable diseases to ( D< via the National Electronic 
Telecommunications System for Surveillance i\l rSS 
NT'.TSS supports the rapid collection and tinielv communica- 
tion ot large amounts of data on conditions of national health 
importance. These data facilitate earlier detection of disease 
characteristics, enabling the CDC to perform analyses and to 
recommend appropriate prevention efforts at the local. State, 
and national level. Innovative analytical methods are being de- 
veloped and evaluated for applicability to public health sur- 
veillance data. New and improved computer software ami epi- 
demiologic workstations are under development that will 
strengthen the ability of federal. State, and local epidemiolo- 
gists to collect, analyze, and communicate surveillance data in 
a tirnelv manner. 



International Health Program 
Office (ihpo) 

The International Health Program Office conducts pro- 
grams to improve the disease prevention and control capaci- 
ties of other nations. Programs focus on decreasing morbidity 
and mortality among infants and children, preventing the 
spread ot HIV infection, improving conditions for refugees 
and persons displaced by national and manmade disasters. and 
strengthening the public health capacities of overseas institu- 
tions to provide services to their own nations. Partnerships 



formed with other international agencies such as the U.S. 
Agency for International Development (I SAID), the World 
Health Organization, the United Nations lntern.irion.il Chil- 
dren's Fund, the United Nations High Commissioner lor 
Refugees, and others facilitate the delivery ol shared technical 
assistance in the assessment of health priorities, planning and 
deliver)' of programs, training of staff, evaluation and follow - 
up, and applied research. 

IHPO Prevention Highlights 

Child Survival Program. The 11 IPO Child Survival Program 
works in partnership with USAID to prevent disease and 
death among children under age 5. 11 IPO staff are assigned CO 
either the Ministry ol I lealth or USAID Missions in IS de\ el 
oping countries. Program efforts strengthen immunization ac- 
tivities, improve malaria and diarrhea case management prac- 
tices, provide training to program managers at the local level, 
improve health education activities, improve health informa- 
tion sv stems, and conduct operational research to improve 
program delivery in all related areas ol child survival. Other 
11 IPO staff arc assigned to programs directed toward the pre- 
vention of 1 11V infection. 

Refugee Health and Emergenc) Response. IHPO coordi- 
nates the CDC response to requests for assistance from na- 
tional and international agencies in natural and manmade 
crises and chemical and environmental emergencies occurring 
outside the I nited States. II IPO staff, concerned primarily 
with the health of refugees, conduct health assessments of 
populations displaced for long or short periods of time, assist 
in setting up disease surveillance systems in temporary camps 
occupied by refugees, and provide appropriate recommenda- 
tions to relict agencies to identify priority needs for the use ot 
scarce resources. II IP( ) coordinates CDC's efforts to identify 
stall with the best scientific, technical, and management ex- 
pertise to assist with problems ranging from epidemic disease- 
control and chemical spills to Hoods, earthquakes, and vol 
canic eruptions. IP1 1() directs a CDC-wide initiative which is 
developing the technical skills and providing increased experi- 
ence to personnel within CDC interested in working in inter- 
national assistance. This initiative will, in time, increase 
CDC's capacity to not only respond to emergencies but also 
help other countries prepare for them. 

HIV/AIDS and STD Prevention and Control. II IPO coor- 
dinates CDC technical assistance lor HIV/AIDS and STD 
prevention and control in a number of developing countries 
generally with support from I SAID. ( )ther support for work 
in HIV/AIDS prevention has been provided by the World 
Hank. CDC advisors currently are based in Bolivia, the Cen- 
tral vlrican Republic. Uganda, and the Republic ot South 
Africa. 



Public Health Practice Program 
Office (phppo) 

The Public Health Practice Program Office supports pro- 
grams to build the public health system's ability to address in- 
creasingly complex health problems that require comprehen- 



Agency Innovations 



sive approaches and increased capacity at the State and local 
levels. This goal is accomplished through (1) expanding the 
knowledge, skills, and abilities, including leadership skills, of 
the public health work force, (2) empowering communities 
and improving the organizational effectiveness of local and 
State health agencies, (3) conducting research in public health 
practice, and (4) enhancing" CDCs ability to communicate 
health information. 

In support of these activities, PHPPO collaborates with 
other CDC programs, State and local health agencies, aca- 
demic institutions, the private sector, professional and volun- 
tary organizations, and national and international health 
agencies. PHPPO cooperates with these groups in conduct- 
ing needs assessments, data acquisition and analysis, program 
development and demonstration, technical assistance, train- 
ing, consultation, and evaluation. Recognizing the important 
role that technology plays in efforts to communicate effec- 
tively with large numbers ot people, PHPPO uses many 
forms of modern technology to develop and communicate 
important CDC messages and to provide instructional and 
informational products to improve the performance of public 
health personnel. 

PHPPO Prevention Highlights 

Building an Effective Public Health Work Force. The 

Public Health Leadership Institute was initiated to enhance 
the leadership skills of city, county, and State health officials. 
During its first 2 years, 105 senior health officials participated 
in the activities ol the Institute. The faculty included subject 
matter experts from the private sector, legislative representa- 
tives, faculty from academic institutions, members of profes- 
sional and voluntary associations, and representatives of Fed- 
eral, State, and local health agencies. The long-term 
objectives of the institute are to: 

• Enhance and develop the leadership skills and abilities of 
participants in areas that are vital to the operation of 
their health agency; 

• Provide an annual forum for discussions and critical 
analysis of current public health issues; 

• Develop a network of public health leaders who can pro- 
vide ongoing support to improving the public health in- 
frastructure following the Institute; 

• Strengthen the relationship between public health 
practice and academia by providing a model for such 
interaction. 

Steps have also been taken to develop a CDC Public 
Health Training Network, which was initiated with presenta- 
tion of the course "Epidemiology by Satellite." This Network 
will provide leadership and direction in training public health 
practitioners using distance-based delivery systems such as 
videoconferencing, self-instructional materials, and comput- 
ers. Rather than public health workers traveling to obtain 
training, training would come to the public health worker — 
in an office, agency, local college or university, or regional 
site. 

In support of CDCs mission to build public health, 
PHPPO has collaborated with other components of CDC to 
develop a wide variety of training materials. Through a coop- 
erative agreement with the Association of State and Territor- 
ial Public Health Laboratory Directors, PHPPO has collabo- 
rated in the development of the National Laboratory Training 



Network (NLTN). NLTN offers regionally based laboratory 
training in seven geographic areas that cover the United 
States. 

Increasing the Effectiveness of Public Health Organiza- 
tions. Under a cooperative agreement with the National As- 
sociation of County Health Officials (NACHO), PHPPO has 
published the Assessment Protocol for Excellence in Public Health 
(APEX/PH). APEX/PH is a workbook that guides local health 
department officials in assessing and improving the organiza- 
tional capacity of the department and in working with the 
local community to assess and improve the health status of its 
citizens. The American Public Health Association, the Asso- 
ciation of Schools of Public Health, the Association of State 
and Territorial Health Officials, and the U.S. Conference of 
Local Health Officers participated in the development of the 
workbook, which has been distributed by NACHO to State 
and local health departments. Staff from NACHO and 
PI IPPO are collaborating with selected State and local health 
departments to develop strategies for effective implementa- 
tion of both APEX/PH and the model standards. 

Communicating Information. PHPPO, the Information 
Resources Management Office, and the Epidemiology Pro- 
gram Office are working in partnership with State and local 
public health departments and academic centers to develop 
the CDC Information Network for Public Health Officials 
(INPHO), an electronic network to link State and local 
health departments with CDC. Available information will 
include: a community health surveillance system that de- 
scribes the health status of the community and State; reports 
of epidemic investigations; guidelines on the delivery of pre- 
ventive health services; training resources; and emergency 
reports. The system will also have electronic mail capability 
by which public health officials can communicate with each 
other. 

Addressing Critical Issues in Health Laboratory Quality. 

CDC recognizes the importance of laboratory testing in iden- 
tifying and managing chronic and infectious diseases. To im- 
prove the quality of laboratory practice in support of public 
health programs, PHPPO is conducting and participating in 
research to identify the critical determinants of laboratory 
testing quality. Questions being examined by the research in- 
clude: (1) the relationships between specific laboratory prac- 
tices and standards and the accuracy and reliability of test re- 
sults, (2) the extent and nature of laboratory errors, and (3) the 
impact of laboratory errors on patient care. 

Building Academic Programs and Relationships. Relation- 
ships with the academic community have been strengthened 
through (1) a cooperative agreement with the Association of 
Schools of Public Health, (2) a cooperative agreement with 
the Association of Teachers of Preventive Medicine, and (3) 
the assignment of experienced public health practitioners to 
schools of public health. These mechanisms are managed by 
PI IPPO for the use of all the operating components of CDC 
and ATSDR. They permit CDC/ATSDR to collaborate with 
researchers and practitioners at health and medical institu- 
tions on research, training, curriculum design, development 
and change, and modification of prevention and public health 
practices. 



Prevention '93/'94: Federal Programs and Progress 



Acquired Immunodeficiency Syndrome (.AIDS). The focus 
of PHPPO's AIDS activities is improvement of laboratory 
testing associated with HTV infection. In addition to the tests 
used for detecting H1Y infection, the most recent improve- 
ment efforts include tests to evaluate the immune status of in- 
fected persons and to provide information for therapy and 
early intervention. Consequently, T-lymphocyte im- 
munophenotyping, especially CD4+ cell determinants, are 
now included in PIIPPO's activities. These activities consist 
of developing guidelines and presenting laboratory training 
courses that teach testing procedures to public health and pri- 
vate sector laboratory workers anil assessing the quality of 
1 1IV testing through a voluntary performance evaluation pro- 
gram. To meet the increasing demands tor training, PI1PPO 
has developed self-mstructional training packages and new 
courses. Courses are delivered at CDC headquarters and 
through the National Laboratory Training Network. 

PI [PPO's 1 11V performance evaluation program serves as a 
model tor evaluating new technologies and tor assuring that 
the quality of testing meets the needs of public health ami pa- 
tient care. About 1.0(10 laboratories that perform H1V-1 anti- 
bod) testing, $20 that perform HTI.V-I/11 antibody testing. 
and 5 JO dtat perform CD4+ cell testing participate in this vol- 
untary program. 

Food and Drug 
Administration (fda) 

The Food and Drug Administration is the regulatory 

agency responsible for assuring thai food is sate and u hole- 
some; drugs, biological products, and medical devices are safe 
and effective; cosmetics are safe; ami the use of radiological 
equipment does not result in unnecessary exposure to radia- 
tion. PDA approves new drugs, food additives and certain 
medical devices before they can be marketed and conducts in- 
spections of related manufacturing anil processing plants. It is- 
sues public warnings when hazardous products arc identified, 
and it is empowered to remove unsafe products from the mar- 
ket. PDA is authorized to initiate legal action against commer- 
cial products containing misleading labeling. FDA's program 
activities are distributed among individual Centers for Drug 
Evaluation and Research, Biologic Evaluation and Research, 
Devices and Radiological Health. Pood Safety and Applied 
Nutrition, Veterinary Medicine, and the National Center for 
I oxicological Research. 

PDA is responsible tor providing regulatory oversight for 
over 90,000 domestic establishments and 500,000 domesti- 
cally marketed products. It is also responsible for regulating 
the safety and quality of approximately 1.5 million import en- 
tries each year. These responsibilities are carried out in an en- 
vironment characterized by increasingly complex products 
and international trade arrangements. FDA inspects both 
firms and products in the domestic and international arenas 
whose violations of safety standards are most likely to expose 
the public to unnecessary risk. FDA is the lead agency for co- 
ordinating activities in the Healthy People 2000 food and 
drug safety priority area and co-lead with NTH on the nutri- 
tion priority area. 



FDA Prevention Highlights 

Anabolic Steroids. As recommended in the 1990 "Report 
from the Interagency Task Force on Anabolic Steroids," FDA 
developed a comprehensive, high-visibility media campaign to 
address the problems ot steroid abuse. Subsequently, new leg- 
islation, the Anabolic Steroids Control Act of 1990 (Public 
Paw 101-647), authorized the Center for Substance Abuse 
Prevention (CSAP) in the Substance Abuse and .Mental 
Health Services Administration to develop and support pro- 
grams to identify and deter the improper use or abuse ot ana- 
bolic steroids by students, especially in secondary schools. 
Pursuant to this new legislative mandate, FDA transmitted its 
program initiatives to CSAP. 

Prescription Drug Patient Education Activities. Since 
1984, FDA and the National Council on Patient Information 

.\\n\ Education have coordinated the development and imple- 
mentation ot major prescription drug patient education ini- 
tiatives in the public and private sectors. The initiatives are 
concentrated in three main areas: urging patients ro request 
information about prescription drugs, encouraging health 
professionals to provide information, and monitoring patient 
education activities. The 1992 "Communicate Before You 
Medicate" campaign was focused on the safe use of medi- 
cines, to cure, control, or prevent many illnesses. Previous 
FDA initiatives included the "Women and Medications" 

campaign that emphasized the sale and effective use of med- 
ications by women — especially pregnant, nursing, and 
menopausal women and minority and older women. Other 
activities include the "Brown Bag Medicine Review Pro- 
gram." and "Can Patient Education Really Make a Differ- 
ence":" campaign. "Talk About Prescriptions Month" (Octo- 
ber). "Making Progress in Medicine Communication: The 
Outcomes Challenge," and "Medicines: What Ever) Women 
Should Know ." 

In December 1991, the Commissioner ol Pood and Drugs 
announced an initiative to call on health professionals to 
begin a new effort to educate patients about their prescription 
drugs. To address (nod and drug safet) objective 12.6 of 
HEALTHS PEOPLE 2000 — targeting increased medication 
counseling lor older Americans, PDA conducted a nation- 
wide random survey in 1992 to develop baseline data on the 
nature and effect of prescription drug information, either ver- 
bally or in written form, received by patients from health pro- 
fessionals, and from other sources. Patients were asked about 
information I eceh ed and about their willingness to seek out 
prescription drug information from health professionals and 
others. 

FDA is working with the American Association of Retired 
Persons to survey customers of their mail pharmacy service to 
identify the types of medication information this population 
group found most beneficial. Results from tested information 
formats will describe the usefulness of such targeted informa- 
tion on affecting knowledge of risk/benefit information and 
will be disseminated nationwide to planners of patient drug 
education programs for the older adult. 

Health Fraud. FDA uses a combination of enforcement and 
education strategies to combat health fraud by working closely 
with many other groups to build coalitions among govern- 
ment and private agencies at the national, State and local lev- 



Agency Innovations 



els. FDA district offices nationwide monitor promotions for 
suspected fraudulent health-related products and orchestrate 
appropriate regulatory action through FDA's National Health 
Fraud Coordinator, whose office maintains a National Health 
Fraud System data base. Since 1989, regional bilingual confer- 
ences have been held to provide practical guidance to individ- 
uals and organizations to combat health fraud, quackery, and 
misinformation. Statewide regional conferences were held in 
Santa Fe, New Mexico, and Miami, Florida, in May 1993. 
FDA has joined with the National Association of Consumer 
Agency Administrators (NACAA) to establish the NACAA 
Health Products Promotions Information Exchange Network. 
FDA, the Federal Trade Commission, the U.S. Postal Service, 
and State and local offices supply information on health prod- 
ucts and promotions, consumer education materials for use by 
print and broadcast media, and contacts in each contributing 
agency. FDA has recently established an office to combat the 
risks to public health presented by advertising fraud and prod- 
uct misrepresentations. 

Health Is Life. FDA, the National Urban League, and the 
Food Marketing Institute are cooperating in a "Health Is 
Life" program, designed to increase consumer knowledge 
about the importance of proper diet and health care. These 
events, focusing on health concerns of African Americans, 
were conducted by Urban Leagues affiliates in Houston, 
Texas; New Orleans, Louisiana; Tallahassee, Florida; Win- 
ston-Salem, North Carolina; Columbia, South Carolina; and 
Richmond, Virginia, in February and A'larch 1993. The pro- 
gram, held in conjunction with Black History Month in Feb- 
ruary and National Nutrition Month in March, will enable 
consumers to modify risk behaviors associated with diet and 
nutrition, as well as to become informed about diet and med- 
ication and the importance ot health care screening, which in- 
cludes mammography, blood pressure, sickle cell disease, 
lupus, cholesterol, and lung disorders. 

Para Vivir Bien. Para Vivir Bien (To Live Well) is a project 
designed to develop nutrition education materials based on 
the Dietary Guidelines for Americans. This will be part of a na- 
tional nutrition labeling education initiative to raise awareness 
of the importance of diet and health among the Hispanic pop- 
ulation. The project will be conducted by COSSMHO (a 
coalition of Hispanic health and human service organizations) 
and is funded by FDA, the Food Marketing Institute, and the 
Human Nutrition and Information Service of the U.S. De- 
partment of Agriculture. 

Community Health Education Centers. The purpose of 
the pilot demonstration, Community Health Education Cen- 
ters, is to create model health promotion and disease preven- 
tion programs through historically Black Colleges and Uni- 
versities (Morehouse School of Medicine, Texas Southern 
University's School of Pharmacy, and Spelman College). The 
project targets programs on patient education, diet and health, 
women's health, and safe use of medications by disadvantaged 
and minority consumers. Through the use of modified low lit- 
eracy materials and dissemination techniques, the project will 
assure access to health information that can help to modify 
risk behaviors associated with diet/nutrition and to become in- 
formed about medications and the importance of mammogra- 
phy screening. 



Breast Implant Information Hotline (1-800-532-4440). 

Through this hotline, the FDA Office of Consumer Affairs 
continues to provide callers with the opportunity to receive 
up-to-date written information on breast implants. In the first 
6 months since its implementation in July 1992, FDA re- 
sponded to approximately 3,500 calls and letters. 

Food Safety. Measures to achieve reductions in lead expo- 
sures from all sources are underway. Standards for new lower 
action levels for leachable lead from ceramics were published 
and are being enforced, and new regulations banning the use 
of lead-soldered cans for food packaging and lead foil seals for 
use on wine bottles have been developed. Efforts are also un- 
derway to better educate consumers of the potential hazards 
associated with improper handling and preparation of seafood 
and to increase participation in the FDA/NMFS Seafood In- 
spection Program. New regulations are being drafted to en- 
sure that infant formula provides a safe, wholesome, and com- 
prehensive source of nutrition. Proposals governing allowable 
limits for contaminants in bottled water have also been pub- 
lished, further ensuring bottled water as a safe food. Carefully 
designed surveys are periodically conducted to assess con- 
sumer awareness between diet-disease relationships, which 
provide valuable data for determining consumer education re- 
quirements. A series of comprehensive regulations has been is- 
sued to improve the utility of the food label as an aid to assist 
consumers in making healthy food choices. 



Center for Drug Evaluation and 
Research (cder) 

FDA's Center for Drug Evaluation and Research is respon- 
sible for assuring that all marketed drug products are safe and 
effective for their labeled indications and that clinical investi- 
gations of not-vet-approved products respect the rights of 
human subjects. The approval of drug products for human use 
subject to regulation under the Federal Food, Drug and Cos- 
metic Act and the Public Health Service Act is based on thor- 
ough review of extensive scientific data and test results sub- 
mitted to CDER by the product sponsor, usually a 
manufacturer who is seeking to market the product. CDER's 
role also includes monitoring the various facilities involved in 
the manufacture and distribution of these products. 

CDER is involved in the development ot a number of treat- 
ments aimed at preventing diseases, such as osteoporosis, 
diabetic complications, cardiovascular disease, cancer, and 
development of AIDS in asymptomatic HIV-infected individu- 
als. CDER reviewers working with the Office of Orphan Drug 
Products assist in the development of preventive treatments for 
conditions affecting as few as a dozen people in the country. 

CDER epidemiologists continue to monitor the occurrence 
of known and previously unidentified adverse reactions to all 
marketed drugs. The information is shared with pharmaceuti- 
cal manufacturers and physicians, to reduce or help prevent 
adverse reactions to marketed drugs. 

CDER Prevention Highlights 

Heart Disease. A number of drugs have been approved for 
the lowering of blood lipids to prevent atherosclerotic, cardio- 



Prevention ' 9 3 / ' 9 4 : Federal Programs and Progress 



© 



vascular disease. While most of these drugs were approved on 
the basis of biochemical data (i.e.. lowering blood cholesterol 
levels), more recent approvals have been supported by mortal- 
it}' and morbidity data. These data will be required in the fu- 
ture before such drugs will be approved. Accumulating data 
iipport the effectiveness of estrogen replacement therapj 
in preventing coronary atherosclerotic heart disease in post 
menopausal women. 

Metabolic and Endocrine Drugs. Estrogen treatment lor 

the prevention of osteoporosis has been approved alter con- 
trolled studies demonstrated reduced rates ol fractures in es- 
trogen treated women. Several drugs have been evaluated for 
the prevention ot the major complications ot diabetes includ- 
ing retinopathy, peripheral neuropathy, and nephropathy. 
While results have been disappointing, this area remains very 
active, and several new therapeutic approaches have recently 
emerged. Trials to prevent prostatic hypertrophy and prosta- 
tic cancer are already underway with a drug previously ap- 
proved tor treatment of symptomatic prostatic hypertrophy. 
Ot major interest is investigation ot compounds that may slow 
some parts ot the aging process. 

\11)S. Several studies have been completed or are underw.u 
by product sponsors m the evaluation ot antiviral drugs that 
mav prolong the asymptomatic period ot people infected with 
I ll\ . In addition, non-viral, anti-microbial agents continue to 
be investigated for their potential value in preventing oppor- 
tunistic infections in UDS patients. \ tew drug treatments are 
in the carlv stages of investigation lor their potential use in 
preventing the malnutrition associated with AIDS. 

Sexualh Transmitted Disease Prevention. ( DER experts 
are involved with colleagues in the Center for Devices and Ra- 
diological Health (CDRH) in efforts to develop standards lor 
the clmic.il testing and manufacture of male and female con- 
doms and spermicides. These products have been shown to 
prevent the transmission of sexually transmitted diseases in- 
cluding AIDS. 

Cancer. \ wide range of compound-, including carotenoids, 

vitamins, and trace elements have shown promise tor the pre- 
vention of various forms of cancer. Estrogen and progesterone 
therapies are being shown to prevent, respectively, cervical 
and endometrial cancer. Tamoxifen, .m estrogen receptor 
blocker, is under evaluation for its value in preventing breast 
cancer in women at high risk tor this problem. 

Accelerated Approval. Final regulations were published in 
December L992 providing tor accelerated approval mecha- 
nisms that utilize earlier indicators of disease progression such 
as surrogate markers to facilitate drug therapy development. 

Over-the-Counter Drugs. CDER has been involved in a 
number of initiatives to define therapies that would safely 
allow patients access to non-prescription drugs. Current edu- 
cational activities include the "OTC Drug Labeling and Chil- 
dren" public education campaign and the public education 
video "Looking at the OTC Label," which featured FDA's 
Commissioner Kessler. A special initiative on OTC drugs has 
resulted in a marketing ban on over 400 ineffective ingredi- 
ents, which included over 100 ingredients promoted for 



weight loss. \ second ban ot over 40(1 additional ineffective in- 
gredients has recently been promulgated. 

HIV. CDER has activel) pursued cooperative efforts with 
N1H and product sponsors to define the most efficient ap- 
proach to performing clinical trials to assess therapies lor the 
prevention ot opportunistic infections that 1 11V patients are at 
high risk of contracting. 

Tuberculosis. CDER has been assisting Nil I and drug man- 
ufacturers in developing new therapies designed to improve 
medical compliance with tuberculosis drug regimens in an 
effort to decrease the probability of drug resistance taking- 
place with a resultant increased spread ot the disease into the 
population. 

Prevention of Birth Defects. CDER coordinated an effort, 
with XIII and CDC, to define environmental exposure to ,i 
probable teratogenic therapeutic agent. Providing informa- 
tion relevant to this exposure in the product's label will assist 
institutions in preventing exposure ot pregnant health care 
workers to a potential teratogen. 



Center for Biologics Evaluation 
and Research (cber) 

FDA's Center for Biologies Evaluation and Research as- 
sures the s.itctv ami effectiveness ol all biological products for 
disease prevention or treatment. These products include bio- 
logical therapeutics; viral, bacterial, anil rickettsial vaccines; 
antitoxins; therapeutic serums; allergenic products; and blood 
products. CBER is responsible lor establishing and maintain- 
ing standards of safety, purity, and potency of all biologicals 
that must conform to the provisions ol both the Public 1 lealth 
Service Act and the Federal Food, Drug and Cosmetic Act. 
Through its laboratory-based regulatory program, CBER 
evaluates and licenses biologics manufacturing firms and 
products; reviews .md improves licensing and batch control 
procedures; develops necessary regulations, compliance pro- 
grams, and guidelines; and removes ineffective, unsafe, or im- 
properly labeled products from the market. 

CBER w.is reorganized into four new offices: Blood Re- 
search and Review; Therapeutics Research and Review; Vac- 
cine Research and Review; and Establishment Licensing and 
Surveillance. The implementation of the Prescription Drug 
User Tee Act of 1992 will provide resources to the Center that 
will complement the new structure and enhance the review of 
new biological products by CBER. 

CBER Prevention Highlights 

Blood Safety. CBER is responsible for the primary public 
health goal of ensuring safety of the U.S. blood supply, includ- 
ing the prevention of transfusion-associated infectious dis- 
eases. Regulatory mechanisms designed to ensure blood safety 
include the establishment of policies, approval authority for 
blood products and establishments, and surveillance and en- 
forcement activities. CBER has recently begun a comprehen- 
sive blood safety initiative designed to (1) ensure compliance 
throughout the blood industry through development and im- 



Agency Innovations 



plementation of sophisticated quality assurance programs, (2) 
reduce toward zero the risk of infection transmission by blood 
transfusion and (3) develop programs to assure accurate public 
perceptions regarding the quality of the blood supply, the ade- 
quacy of the efforts of the blood industry, and the appropri- 
ateness of FDA policies and procedures. 

Safety of the Blood Supply. To reduce exposure to HIV, 
CBER has developed and recommended improved methods of 
donor selection, including face-to-face medical interviews and 
the use of direct questions about high-risk behavior. CBER 
has also licensed a screening test for antibodies to HIV-2 and 
will soon approve combination tests for detection of antibod- 
ies to HIV- 1 and HIV-2 in anticipation of an eventual need to 
screen donations for HIV-2. To reduce transmission of he- 
patitis, CBER has licensed and recommended use of a screen- 
ing test for antibodies to hepatitis C. Additionally, licensure of 
plasma derived and recombinant Factor VIII preparations and 
Factor IX produced with improved methods of viral inactiva- 
tion will further prevent both HIV and hepatitis infections in 
patients with hemophilia who receive these products. CBER is 
also attempting to reduce errors and accidents in blood estab- 
lishments through educational efforts, increased requirements 
for reporting and more intensive inspections. 

In addition, CBER has recently licensed anti-hepatitis 
B-core and anti-hepatitis C antibody kits, tests that aid in the 
diagnosis of ongoing or previous hepatitis infection. These 
products are widely used to screen blood intended tor trans- 
fusion to detect some cases of hepatitis B infection that are not 
detected by the FDA-required test for hepatitis B surface 
antigen. 

Vaccines. FDA has recently approved 2 DTP vaccines con- 
taining acellular pertussis to be used for immunization at the 
time of 4th and 5th doses. FDA's scientists have collaborated 
with NIH in the laboratory and clinic where acellular pertussis 
vaccines are being evaluated in infants which offer the poten- 
tial of being less reactive in these children. In addition, a 
Japanese encephalitis vaccine was approved after further eval- 
uation of the information available on safety and efficacy; this 
vaccine may be offered to selected travelers to sites at high risk 
for disease. 

The annual reformulations of influenza vaccine assure pro- 
tection against prevalent strains and offer protection to those 
who are at greatest risk. CBER also sponsored a workshop di- 
rected at methods to be used to evaluate polio neurovirulence. 

The decade of the 1990s may see the introduction of sev- 
eral new vaccines including vaccines against typhoid fever, 
additional polipaccharide conjugate vaccines, new types of 
hepatitis, and multiple combination vaccines. AIDS vaccine 
research continues to be of high priority. FDA is working 
closely with NIH and other agencies on trial design and eval- 
uation criteria. 

FDA recently approved the use of two vaccines against He- 
mophilus B, the leading cause of bacterial meningitis. Already 
licensed for children beginning at 18 months of age, the new 
use of Hemophilus B vaccine in infants as early as 2 months of 
age is expected to prevent the majority of Hemophilus B in- 
fections, which frequently strike children between 6 and 12 
months of age and can lead to brain damage and death in in- 
fants. This licensing action represents the first approval of a 
vaccine for routine use in infants in almost 30 years. 



Biotechnology. Advances in biotechnology, particularly ge- 
netically engineered organisms, have led to safer and more ef- 
fective diagnostics, therapeutics, and vaccines. CBER main- 
tains up-to-date knowledge of biotechnological techniques 
and methodologies. It sponsors and conducts research to fos- 
ter the development of new products and provides a sound sci- 
entific basis for their regulation. An emerging area of develop- 
ment is somatic cell and gene therapy. 

Acquired Immunodeficiency Syndrome (AIDS). CBER 
scientists are evaluating the specificity of immune responses 
induced by candidate AIDS vaccines and developing informa- 
tion needed to evaluate vaccine safety and efficacy. In addi- 
tion, CBER is making important contributions to the search 
for therapeutic approaches to AIDS. 



Center for Food Safety and 
Applied Nutrition (cfsan) 

The Center for Food Safety and Applied Nutrition moni- 
tors the food and cosmetic industries to provide consumers 
with the best possible assurances that foods and cosmetics are 
honestly labeled, safe, nutritious, and wholesome. CFSAN's 
regulatory strategy includes conducting inspections of food 
establishments and analyzing food samples to detect and re- 
move hazardous foodstuffs from the market; conducting, sup- 
porting, and encouraging research to detect and determine 
what agents, occurring naturally or added to food, may be in- 
jurious to health; reviewing industry petitions to permit safe 
use of food and color additives; conducting nutrient analyses 
and food labeling initiatives including implementing the 1990 
Nutrition Labeling and Education Act; complying with nutri- 
tion labeling regulations and the Infant Formula Act; en- 
hanced monitoring" of seafood safety coordinated through the 
new Office of Seafood; monitoring levels of pesticides and 
other chemical contaminants in the food supply; promoting 
adoption of uniform model codes; and providing guidance, 
training, technical assistance, and evaluation of State and local 
food safety programs. 

CFSAN Prevention Highlights 

Seafood Safety. CFSAN's Office of Seafood is managing a 
number of initiatives aimed at assuring the safety of seafood. 
One initiative involves a national chemical contaminants con- 
ference to obtain information that will be used by FDA as part 
of its risk management, communication, and assessment activ- 
ities. Another initiative involves educating certain immuno- 
compromised populations about the special risk from marine 
bacteria of the vibrio species, which should only be eaten after 
thorough cooking. FDA is also working with States to upgrade 
the entire safety program for molluscan shellfish. A third ini- 
tiative involves the development of international agreements 
with countries that export seafood to the United States to as- 
sure that their government programs are equivalent to U.S. 
programs. Seafood research, mandator)- inspections of proces- 
sors, sampling and export examinations have been upgraded or 
are in the process of being upgraded. FDA and the National 
Oceanic and Atmospheric Administration are piloting a spe- 
cial program to enhance safety and quality of seafood at retail 



Prevention '93/'94: Federal Programs and Progress 



establishments by using Hazard Analysis Critical Control 

Point .11 U CP) principles with the seafood industry. 

Infant Formula. The Food, Drug and Cosmetic Act was 
amended by the Drug Enforcement, Education and Control 
Act of 1986 (Public Law 99-570) to address concerns ex 
pressed about the regulation of infant formula manufacturers. 
These 1986 amendments require FDA to publish new or re- 
vised regulations concerning current good manufacturing 
practices, qualitv control procedures, consumer complaint 
files, recalls, manufacturers' audits, nutrient testing, testing 
tor potential microbiological and chemical contaminants and 
associated record retention to document the fulfillment <>l 
these requirements for infant formulas. 

On human 26, 1989, FDA published in the Federal Register 
a proposal (54 FR 3783) to revise its infant formula regula- 
tions with respect to records retention, microbiological and 
nutrient testing, manufacturers, audits, and consumer com- 
plaints. The final rule was issued in 1993. FDA is in the 
process of developing good manufacturing practices regula- 
tions lor infant formula manufacturers to help ensure a sale. 
wholesome, and complete source ol nutrition tor infants. 

Health and Diet Surveys. l 1 SAN conducts consumer sur- 
veys to estimate the prevalence and population distribution ol 
health behaviors related to dietary concerns and to track pub- 
lic awareness, know ledge, and concern with diet-disease rela- 
tionships. Data on diet-disease relationships are available lor 
the perioil 1 for the general population, as well as for 

ohler adults .\m\ racial and ethnic minorities. Recent studies 
have examined the prevalence ol various weight-loss practices 
and types of weight-loss regimens, usage styles ol vitamin .w\A 
mineral supplement consumers, infant feeding practices dur- 
ing the tirst 12 months of life, food handling practices and 
awareness of microbiological food hazards, and the prevalence 
ot different kinds ol nutrition label uses and competencies to 
use nutrition labels tor various purposes. These surveys are 
part ot the National Nutrition Monitoring System, which 
Supports a variety of public education, evaluation, and policy 
initiatives. 

Molecular Biology Research. Application ot recombinant 
DNA technology tor the identification ot potential pathogens 

in toods has been ongoing within CFSAN. Synthetic genetic 
probes tor Listeria monocytogenes, Shigella spp., Yersinia enterco- 
litica, and enterobemorrbagic /•.'. cdi 0157:H7, to name a tew, 
have been developed at CFSAN and applied by Office of Re- 
gional Operations field microbiologists. Onsite capabilities 
tor synthesis, purification, and labeling of such probes ensure 
that CFSAN is able to quickly respond to potential concerns 
about the safety ot our tood supply. Non-radioactive chemi- 
luminescenr probe methodologies have been exploited within 
CFSAN to supplant the use of radioactivity, normally used in 
probing analysis. Using a bacterial paradigm, non-radioactive 
methods have been developed that permit discrimination of a 
single base-pair mismatch. Such techniques should make the 
use of genetic probes more palatable to the community at 
large. Polymerase chain reaction (PCR) is a versatile tech- 
nique that permits ready /';/ vitro amplification of DNA. The 
technique has been used within CFSAN, for example, to de- 
velop rapid methods for detection of bacterial and viral 
pathogens. Because the technique obviates the need for cell 



culture, even those pathogens refractory to growth in vitro 
cm be detected readily with PCR. A combination ot' P( 1R and 
genetic probe analysis is being used tor the detection ot he- 
patitis \ and \oiwalk agent in shellfish and other foods. PCR 
is being used in concert with mismatch analysis to quickly 
identity' unique markers for particular pathogens. Such an ap- 
proach, for example, is proving integral to the design of spe- 
cific probes for Salmonella enteritidis. The products of this re- 
search are being utilized, not onl\ l>\ IDA. but by other PHS 
agencies. 

Nutrition Labeling. On Januarj 6, 1993, DHHS published 

final rules to improve the utility ot the tood label in making 
health) tood choices. These regulations are based on FDA's 
evaluation ol comments to proposals it published on Jul) 1 () . 
1990, M\d November 27. 1991. The regulations implement 
the provisions ot the Nutrition Labeling and Education Act 
ol 1990 (Nl I \>. Signed into law on Novembers. 1990, the 
goals anil provisions ot the Nl.T.A will require changes in al- 
most every food label. Beginning Alav S, 1993, labels must 
contain improved ingredient listing information and the per- 
centage juice content for fruit and vegetable juice products. 
Beginning May 8, 1993, the labels lor food products contain- 
ing health claims must conform to the requirements of the 
final rules to ensure the validity of the claims. Beginning May 
S. I ( ' ( '4, the labels lor almost all packaged food products must 
include improved nutritional information and the use of nu- 
trient content claims (i.e.. descriptor claims such as low and 
light) must conform to the new requirements of the final 
rules. Under a provision of the NI.I-'A, retailers have been 
voluntarily providing nutritional information on raw produce 
ami fish since November 2", [991. Once the food industry 
implements all ol the tood labeling changes, consumers will 
be able to find complete nutrition information on most pack- 
aged foods, raw produce, and fish. The revised labels will 
make it possible to compare serving sizes lor similar items; 
nutrient content claims will be clearly defined; health claims 
will be regulated to ensure that they are supported by signifi- 
cant scientific agreement; anil ingredient statements will be 
more informative. FDA has undertaken a consumer educa- 
tion program to inform consumers about the changes and the 
importance ol label information in maintaining healthy di- 
etary practices. 

Health Claims on food Labels. Health claims are labeling 
statements that expressly or by implication characterize the 
relationship ol any substance (i.e., a specific tootl or compo- 
nent of food) to a disease or health-related condition. The 
\ I.I \ provides that food labels may contain only those health 
claims that have been specifically authorized by the FDA. On 
January 6, 1993, IDA published a regulation providing gen- 
eral guidance concerning health claims and the submission of 
petitions to obtain FDA approval of health claims. FDA also 
published final rules authorizing several health claims to be 
used on food labels. The intent of the regulations is to allow 
claims that inform consumers about how selected dietary pat- 
terns mav influence the occurrence of specific diseases and to 
assist consumers in making informed dietary choices at the 
point of purchase. It is important that these statements be 
truthful and balanced, neither misleading the consumer nor 
overemphasizing the role of a specific food and its place in the 
context of a total diet. 



Agency Innovations 



Center for Devices and 
Radiological Health (cdrh) 

FDA's Center for Devices and Radiological Health devel- 
ops and implements national programs to protect the public- 
health in fields of medical devices and radiological health. 
These programs are intended to assure the safety, effective- 
ness, and proper labeling of medical devices and to prevent 
unnecessary human exposure to potentially hazardous ionizing 
and non-ionizing radiation and to ensure the safe and effica- 
cious use of such radiation. CDRH issues standards for radia- 
tion-emitting products, develops recommendations on safe ra- 
diation practices, and conducts education programs on 
radiation protection for health professionals and consumers. 
CDRH classifies medical devices into various regulatory 
groups, depending on the degree of control necessary to en- 
sure each device's safety and effectiveness. CDRH reviews 
clinical data for devices that require approval before market- 
ing. CDRH requires the use of Good Manufacturing Prac- 
tices, requires that devices bear adequate labeling, provides 
guidance to industry on how to comply with all requirements, 
and periodically reviews and revises the list of critical devices. 
CDRH also conducts research and testing related to medical 
devices, collects and evaluates data for device-related hazards, 
and conducts education programs for health professionals and 
consumers on the safe and effective use of medical devices. 

CDRH Prevention Highlights 

Acquired Immunodeficiency Syndrome (AIDS). CDRH's 

Office of Device Evaluation has implemented a priority re- 
view program to ensure that devices with specific AIDS pre- 
vention, diagnostic, or therapeutic claims are evaluated as 
quickly as possible. For devices already on the market that are 
intended for prevention of HIV transmission (e.g., latex con- 
doms and surgical and examination gloves), the Office of 
Compliance and Surveillance collects samples for product 
testing. Postmarketing surveillance data is necessary to ensure 
that these devices are adequately labeled for the intended 
users. In order to assess the risk of transmission ot bloodborne 
pathogens, including HIV, through condoms and medical 
gloves, the Office of Science and Technology continues to 
conduct laboratory research on the barrier effectiveness of 
these devices. Since 1991, the Office of Training and Assis- 
tance has been distributing its booklet, Condoms and Sexually 
Transmitted Diseases... Especially AIDS, to educate the public, 
health and medical professionals, and health educators on the 
proper selection, storage, use, and quality assurance of con- 
doms. In FY 1993, a Spanish language version was distributed. 

Anesthesia Education. In response to studies and data indicat- 
ing that patient injuries and deaths related to anesthesia were 
often due to machine setup errors and faults present in the anes- 
thesia device prior to use, CDRH developed a pre-use checkout 
recommendation. Follow-up studies revealed that the FDA 
checkout procedure list was underused. In FY 1991, CDRH 
began studies with the anesthesia community to determine what 
types of changes in the checkout recommendation made it eas- 
ier to use and to better motivate anesthesia professionals to fol- 
low the suggested checkout procedures. In 1992, CDRH re- 
leased a new proposed anesthesia machine checkout list. 



Hemodialysis. End Stage Renal Disease patients are totally 
dependent upon dialysis treatments for survival until they suc- 
cessfully receive a kidney transplant. If a transplant is not pos- 
sible, they may need dialysis for the remainder of their lives. 
Because of the nature of the treatment, patients are vulnerable 
to possible hazards that can occur during dialysis. Some of 
these hazards arise from failure to maintain and use the equip- 
ment properly. Others arise from the various dialysis compo- 
nents. CDRH has initiated efforts to alleviate these problems. 
In association with patient groups, health professional organi- 
zations, and industry, CDRH has developed several video- 
tapes for the hemodialysis community. These include videos 
on quality assurance, infection control, water treatment and 
reuse, and basic dialysis. In addition to information on dialysis 
equipment and its limitations, the videos include general in- 
formation about the kidneys and how hemostasis is main- 
tained by artificial means when the kidneys stop functioning as 
a result of disease or injury. CDRH is presently addressing is- 
sues involving adequate and effective safe reuse of dialyzers by 
the same patients. 

Mammography Quality Assurance. CDRH develops educa- 
tional materials for women and their physicians on how to 
identify facilities that have mammography equipment, proper 
techniques, trained and experienced radiologists and technol- 
ogists, and good quality assurance. CDRH also monitors the 
practice of mammography through a cooperative program 
with State health departments and works with the radiology 
community to improve the overall quality of mammographic 
practices. In 1992, CDRH provided technical assistance to 
HCFA for implementation of new mammographic quality as- 
surance legislation. 

Apnea Monitors. Infants, otherwise appearing healthy, can 
be prone to cessation of breathing episodes referred to as 
"apnea." Apnea monitors are devices intended to measure or 
monitor a patient's respiratory rate and to notify providers of 
apnea episodes quickly. CDRH initiated development of a 
mandatory performance standard for apnea monitors. The 
published draft standards are intended to set minimum perfor- 
mance requirements that provide a reasonable assurance of 
safety and effectiveness. 

Toxic Shock Syndrome (TSS). Studies show that higher ab- 
sorbencv tampons are associated with an increased risk of 
TSS. In 1989, FDA issued final regulations requiring tampon 
manufacturers to label the absorbency of their products so 
that the current terms correspond to standardized ranges of 
absorbency. This has enabled purchasers to compare brands 
and buy lower absorbency products to reduce their risk of 
contracting TSS. CDRH updated its TSS education pamphlet 
and learning unit and mailed them to health educators and 
school nurses in public, private, and parochial junior and se- 
nior high schools. This revised poster-format learning unit is 
to be used to inform new tampon users, particularly high-risk 
groups such as young women and teenage girls, of the associa- 
tion between tampon absorbency and TSS risk. 

Extremely Low Frequency (ELF) Radiation. Under the 
Radiation Control for Health and Safety Act of 1968, FDA 
has authority to regulate electrical products that emit electro- 
magnetic fields if it can be shown that these products pose a 



Prevention 93/94: Federal Programs and Progress 



public health hazard. As a result of recent epidemiological 
studies, which suggest a relationship between exposure to 

ELF fields and cancer, ami possibly to birth defects. CDRI1 
has focused attention an this issue. The products of most con- 
cern to CDRH ate electric blankets and \ideo display termi- 
nals. After briefing the Technical Electronic Product Radia- 
tion Safen Standards Committee on the scientific and 
regulatory aspects of this issue, the Center has developed a 
strategy lor working «uh manufacturers to voluntarily reduce 

ELF emissions. 

Breast Implants. There has been growing concern over 

problems associated with silicone breast implants and with the 
body's reaction to silicone. In addition to CDRH's recent ac- 
tion restricting use of these implants while more data are col- 
lected. CDPJ 1 has convened a working group to develop edu- 
cational materials on silicone breast implants. The group is 
committed to making available information on the currently 
known risks and benefits of silicone breast implants to 
prospective implant patients. This will assist patients in mak- 
ing an informed decision on the appropriateness ol these de- 
vices. Limited availability of silicone gel implants continues 
while additional data is being collected and clinical studies are 
conducted. 

11) \ has announced the start ol a process t,> require manu- 
facturers ol saline breast implants to submit evidence that the) 
are sate and effective. In addition, it will propose to call lor 
safety and effectiveness data on testicular and penile implants, 
devices that were also on the market before 1976, when FDA 
was given regulator)' authority over them. 

Device-Mediated Bloodborne Infections. \s main as 
00 health care workers are injured by accidental needle 

sticks annually. Between 2(10 and 300 health care workers die 
upationally acquired hepatitis 15 annually, with thou- 
sands more infected per year. Many have acquired the 111V 
\ irus from such occupational exposures as well. CDRH collab- 
orated with CDC anil OSI LA on a conference on the role of 
devices such as needles in transmitting bloodborne infections 
such as I IIV ami hepatitis B. 

Physical Restraints. In response to deaths, injuries, and mis- 
use or abuse of physical restraint devices. (d)RII is in the 
process of increasing the level of scrutiny prior to marketing 
approval of these devices and is developing educational mate- 
rials to help minimize the risks of use. These efforts are con- 
sistent with new HCFA regulations of physical restraint use in 
long-term care facilities. (d)RII has used safety alerts to in- 
form users of certain measures to reduce risks. The Center has 
cleared over 50 risk reduction products for the market and is 
evaluating methods of supporting a move to safer products 
that eliminate or shield the user from injury by sharp ends. 



Center for Veterinary Medicine 
(cvm) 

FDA's Center for Veterinary Medicine is responsible for as- 
suring that animal drugs and feed additives are safe and effec- 
tive and that meat, milk, and eggs derived from treated ani- 
mals are free from harmful or illegal residues. C\*AI carries 



out these responsibilities through premarketing product re- 
view, post-marketing surveillance and compliance activities, 
and educational initiatives. Eighty percent of the meat-pro- 
ducing animals in the United States receive medicated feed or 
drugs at some time during production. 

In the mid-1980s, an FDA investigation revealed a nation- 
wide, loosely knit network of persons involved in the black 
market trade ol bulk animal drugs. Investigations by IDA 
have resulted in charges ol conspiracy, smuggling, folse state- 
ments, adulteration, and misbranding (inadequate directions, 
unregistered manufacturer). To dale, there have been 52 
guiltv pleas, involving 5 veterinarians, 6 import brokers, and 2 
smugglers and over 30 felony pleas. Is prison sentences, and 
Si million in seized goods. 

Recently, residues in milk resulting from the illegal use of 
sulfamethazine (S.\1X) anil other drugs in lactating dairy cattle 
have become a problem. FDA issued warnings to dairy farm- 
ers and veterinarians against the illegal use ol SMZ in animals 
producing milk lor human consumption. SMZ has been iden- 
tified bv FDA scientists as a potentially dangerous drug that 
cannot be used in food-producing animals safely as long as il- 
legal drug residues result from such use. In 1991, FDA initi- 
ated the National Drug Residue Milk Monitoring Program, 
which routinely tests raw milk tor drug residues. Information 
ted under the plan is used in Federal, State, and local 
daily tanner and industrv education and compliance efforts. 
( A M's educational message in this and other programs is pre- 
vention. 1 1)\ has conducted several workshops and sympo- 
siums to inform industrv and others about proper drug use, 
i.e.. "Prevention ol Unwanted Drug Residue," "Proper Ani- 
mal Drug I si' Developing an Agenda for the Nineties," 
"Feed Quality Assurance \ System-Wide Approach," "IR- 
4 FDA Workshop tor Minor Use Drugs —Focus on Aquacul- 
ture," "Good Vlanufacturing Practices lor Animal Drug Man- 
ufacturers," and "Perspectives on food Safety." In addition, 
FDA has an exhibit that promotes the proper use of veterinary 
drugs; the exhibit is displayed at major agricultural and veteri- 
nary events. More than 2511,000 animal producers, veterinari- 
ans, agricultural communicators and consumers attend these 
meetings each year. 



National Center for Toxicological 
Research (nctr) 

The National Center for Toxicological Research (NCTR) 
is a research facility that serves the regulatory needs of FDA. 
NCTR's research efforts study the biological effects of poten- 
tially toxic chemicals and the complex mechanisms that gov- 
ern their toxicity. Collectively, these programs seek to define 
risks to human health from exposure to toxicants in foods, an- 
imal, and human drugs, cosmetics, medical devices, and bio- 
logics and to improve FDA's ability to predict the human risk 
factor imposed by toxic agents. In addition, NCTR conducts 
studies of dose-response relationships for evaluation of genetic 
aberrations, birth defects, cancer, and biochemical and meta- 
bolic alterations induced in animals and their relevance to 
human health. Research conducted at NCTR and other insti- 
tutions on the bioactivation of toxicants raises doubt about the 
reliability of the standard animal bioassav in assessing human 
health risk. Research on Secondary Mechanisms of Toxicity 



Agency Innovations 



investigates the role of normal biochemical processes in the 
bioactivation of compounds that result in a toxic response. 
NCTR's program on quantitative risk assessment and extrap- 
olation addresses the underlying assumptions associated with 
establishing human health standards, to include extrapolating 
animal data to man. Chemical methods, particularly the evalu- 
ation of biomarkers, will allow scientists to monitor toxicity 
within the human population. Recognizing that humans han- 
dle activation or detoxification of chemicals in different ways 
and that genetic factors play a role in how an individual deals 
with toxic exposure. FDA may be better able to predict risk 
within certain subsets of the human population through more 
finely tuned biochemical markers of toxicity. 

NCTR, in conjunction with the National Institute on 
Aging and FDA's Center for Food Safety and Applied Nutri- 
tion, is actively pursuing research that explains the role diet 
plays in toxicity and is in year 6 of a 10-year Project on Caloric 
Restriction. Food contaminants occur in a large portion of the 
products FDA regulates. NCTR, through its program on Nu- 
tritional Modulators of Risk and Toxicity, is exploring the role 
DNA methylation plays in toxicity and is evaluating the effects 
heavy metals have on human health. 

Methods Development for Regulatory Needs. Concern for 
safe and effective foods and drugs requires development of 
new, more accurate methods to evaluate foods and drugs for 
toxic substances that may pose a risk to human health. Current 
procedures, while accurate, are subject to individual interpre- 
tation and variation. As more products are imported from for- 
eign countries with different regulatory requirements, FDA 
must develop methods for testing these imports. Since it is un- 
ethical to test chemicals on pregnant women, the develop- 
mental toxicity program validates improved animal models for 
detection of developmental toxicants. These data, in turn, are 
used to develop improved biologically based dose response 
models to aid in developmental risk assessment in humans. 

NCTR Prevention Highlights 

Biochemical and Molecular Markers of Cancer. Difficulty 
exists in extrapolating risk from animals to humans and in de- 
termining the significant biological exposure. This program 
develops quantitative toxicity indicators of human exposure 
and/or effect and predicts individual/population susceptibility 
to the toxic effects of specific chemicals or classes of chemi- 
cals. The ultimate goal is to predict a toxic response in humans 
by using biological endpoints as markers and to better under- 
stand human exposure and susceptibility based on evaluation 
of these biomarkers. 

NCTR is developing a comprehensive scientific data base 
to reduce the uncertainty in risk assessment/risk benefit analy- 
sis for specific chemicals. This program is a cooperative effort 
between FDA with funding coming primarily from the Na- 
tional Toxicology Program. 

Nutritional Modulators of Risk and Toxicity. The identifi- 
cation of nutritional components that can modulate the toxic 
chemical response is necessary for understanding risk and the 
rational extrapolation of animal data to humans. Incorporated 
into this program are studies dealing with the effects of essential 
nutrients on human risk. Approximately one-third of human 
carcinogenic risk can be ascribed to toxicants in the diet and/or 



to the interactions of diet and toxicants. This program explores 
the adverse effects of dietary toxicants through an understand- 
ing of the mechanisms by which natural protection occurs. 

Quantitative Risk Assessment/Extrapolation. Regulatory 
decisions regarding toxic substances often are based upon esti- 
mates of risk generated via scientific consensus. These esti- 
mates of risk are generated more frequently through quantita- 
tive risk assessment using human and/or animal data to 
estimate the risk of toxic reaction from human exposure to 
toxic substances. This program addresses problems involved 
in the extrapolation of risk estimates across species, from 
high-to-low doses, from continuous-to-intermittent exposures 
and from single substances-to-complex mixtures. 

Secondary Mechanisms of Toxicity. Exposure to toxic 
chemicals can result in a direct risk to an organism, or it may 
result in indirect modifications of a process that ultimately re- 
sults in a toxic response. Since these responses are often highly 
species-dependent, this program is designed to assess non- 
genotoxic mechanisms and the secondary effects of genotoxic 
chemicals (e.g., induction of cell proliferation; alteration in 
specific gene expression in humans and experimental animals). 

Solid State Toxicity. Research will evaluate the potential tox- 
icity of the materials used in medical devices. With the onset 
of replacement therapy for diseased or dysfunctional organ 
systems, long-term exposure to synthetic polymers may occur. 
There is little or no toxicity information available for long- 
term exposure to these compounds. Research in this program 
will provide the data needed to make informed risk decisions 
when reviewing and approving new devices. 

Transgenics. FDA has a need to develop animal models that 
mimic human response. The development of transgenic mod- 
els represents a new opportunity to insert human genes into a 
test animal in such a way as to mimic the human biological re- 
sponse to drugs, carcinogens, and other chemical or biological 
agents. This program will capitalize on the animal facilities 
available at NCTR. 

Applied and Environmental Microbiology. Microorgan- 
isms play an important role in the metabolic activation and 
detoxification of toxicants that enter the human food chain. 
This program will apply microbiological principles and 
methodologies, such as the model human intestinal microflora 
culture systems and environmental microcosms, to determine 
the effects that novel food additives have on the intestinal me- 
tabolism and microbial ecology of the lower intestinal tract. 
Food additives are regulated by FDA and intended for use in 
the human diet at micronutrient levels. Initial focus in this ef- 
fort will be on indigestible or poorly digestible micronutrient 
replacement products with molecular structures that are not 
common in food. 

Developmental Toxicology. Procedures being developed 
will detect a full range of toxic manifestations throughout the 
development of the organism. These studies will expand the 
knowledge of basic developmental processes as affected by 
toxicants, and to define the mechanisms accompanying birth 
defects in humans and experimental animals. This research 
develops a sound data base of comparative pharmacokinetics, 



Prevention 93/94: Federal Programs and Progress 



metabolism and biomarkers in the developing animal to define 
and validate mathematical models for extrapolation ol animal 
data to humans. 

NeurotoxicologY. The overall goals of die neurotoxicology 
program are to develop and validate quantitative biomarkers 
of neurotoxicity and to use these biomarkers to elucidate 
mechanisms and enhance the certainty oi assumptions under- 
lying risk assessment of neurotoxicants. The approach to these 
goals has been development of a multidisciplinary approach 
that integrates neurochemical, neuropathological, neurophys- 
lcal. and behavioral assessments to determine effects and 
mechanisms in neurotoxicoloey. 



Health Resources 
and Services 
Administration (hrsa) 



The Health Resources and Sen ices Administration pro- 
vides leadership in assuring the support for and access to the 
delivery of primary and preventive health care and related 
support sen ices, particularly to the disadvantaged and under- 
served. URSA also develops health resources, encourages the 
geographic distribution of qualified health professionals, and 
strengthens sen ice facilities to meet the health needs ol the 
Nation. URSA supports State- and community-based efforts 
to plan, organize, and deliver primary anil preventive health 
care programs designed to strengthen the overall public health 
system, particularly to the underserved in rural areas, and in 
urban communities. 

HRSA's approach to closing the gaps in access to health 
care sen ices is to link what are often considered separate parts 
of the health care system — public health, primary care, and 
health professions training, into an integrated health care 
model. This integrated approach is fundamental to HRSVs 
ability to accomplish its mission. 

IIRSA has either die lead or co-lead responsibility with 
CDC for several HEALTHY PEOPLE 2000 priority areas. 

Each of HRSA's four bureaus contributes to the prevention 
activities carried out by die Agency: the Bureau ot Primary 
Health Care, the Maternal and Child Health Bureau, the Bu- 
reau of Health Professions, and the Bureau of Health Re- 
sources Development. In addition, die Office of Rural Health 
Policy coordinates and funds a variety of programs that con- 
tribute to the prevention effort. 



Bureau of Primary Health Care 
(bphc) 

The Bureau of Primary Health Care (BPHC) helps assure 
the delivery of health care sendees to residents of medically 
underserved areas and persons with special health care 
needs. BPHC provides prevention-oriented primary care 



services to underserved populations through community 
health centers and to migrant and seasonal farm workers 
and their families through migrant health centers. It assures 
the availability of health care in health professional shortage 
areas by placing health care providers through the National 
Health Service Corps (NHSC). The NHSC Scholarship 
Program and the Loan Repayment Programs assist with 
these placements. 

Through grants to or contracts with State and local public 
and private entities. BPHC provides funds to meet the needs 
oi special populations such as die homeless, victims of black 
lung disease, substance abusers, residents of public housing, 
persons in need of home health services, and persons uddi 
Alzheimer's disease, h also provides leadership and direction 
for the National Hansen's Disease Program; promotes, plans, 
implements, and evaluates comprehensive occupational healdi 
programs within Federal agencies; and administers a health 
benefits program tor designated PUS beneficiaries. 

BP1 IC has an ongoing commitment to the basic mission of 
providing primary care sen ices to at-risk, low-income popula- 
tions that are not otherwise served by the health care delivery 
system. In addition, it recognizes that its program operations 
must adapt to the changing nature ami needs of those popula- 
tions and environments. To accomplish its mission, BPHC 
continues to develop linkages with Federal, State, and local 
health, social service, ami financial agencies, health profes- 
sional groups, and others with related interests to increase ac- 
cess to primary care services lor the medically underserved 
and special population groups. 

BPHC Prevention Highlights 

Community/Migrant Health Centers (C/MHCs). 

(' Nil ICs are community-controlled primary care practices 
that are a vital part of the Nation's health care system, provid- 
ing quality care to medically underserved urban and rural pop- 
ulations. Across the Nation, 550 C/MIICs provide basic pri- 
mary medical care services with a culturally sensitive, 
family-oriented focus that emphasizes health promotion and 
disease and injury prevention. In addition to essential ancillary 
services such as laboratory, radiology, translation, case man- 
agement, and pharmacy sen ices, many centers provide trans- 
portation, nutrition, health education, and onsite dental ser- 
vices. Sen-ices are tailored to meet the specific needs of the 
communities served, including the needs of special population 
groups such as the HIV-infected, substance abusers, and the 
homeless. Most important, C/MHCs are part of systems of 
care, networking with local health departments and other 
agencies in the community to meet the needs of patients and 
their communities. 

C/MHCs have a significant impact on their target popula- 
tions, especially in activities and issues targeting prevention. 
C/MHCs have contributed to lower infant mortality rates, re- 
duced hospitalization rates, and decreased hospital days for 
their user population. Additional activities that focus on im- 
proving the health of the underserved include: 

• Development and implementation of C/MHC preven- 
tion-oriented clinical measures for all five life cycles 
(perinatal, pediatric, adolescent, adult, and geriatric); 

• Establishment of cooperative agreements with private 
foundations to foster primary care and prevention in 
C/MHCs; 



Agency Innovations 



• Support for the Migrant Clinicians Network (MCN), 
which has developed culturally specific health promo- 
tion/disease prevention materials targeted to migrant 
and seasonal farm workers; 

• Support of other clinical networks and joint prevention 
activities such as the Clinical Directors Network of Re- 
gion II and the National Cancer Institute Prescribe for 
Health project to disseminate early cancer detection and 
prevention strategies among primary care providers; 

• Compilation of a compendium of preventive health ser- 
vices provided by C/MHCs; 

• Integration of CDC's Planned Approach to Community 
Health (PATCH) into the C/MHC program; and 

• Dissemination of health promotion/disease prevention 
material to C/MHCs and State health agencies through 
the National Clearinghouse for Primary Care Informa- 
tion, which maintains relationships with other Federal 
and private health information clearinghouses. 

Black Lung Clinics Program. Preventive health services are a 
major component of this program, which provides health care 
to active and inactive coal miners with respiratory and pul- 
monary impairments. Preventive services focus on reducing 
the incidence and severity of pulmonary disease and disability 
through health education and smoking cessation programs. 

National Health Service Corps (NHSC). The National 
Health Service Corps addresses inequities in the geographical 
distribution of health personnel resources by the develop- 
ment, identification, placement, and maintenance of a highly 
qualified health work force of primary care providers. NHSC 
has placed highest priority on the recruitment of obstetri- 
cians/gynecologists, family practitioners, nurse practitioners, 
physician assistants, and nurse midwives in support of DHHS 
initiatives in pregnancy and infant health and the control of 
sexually transmitted diseases. NHSC continues to target its 
resources on high-priority areas to provide health personnel 
in support of BPHC initiatives. In FY 1992, NHSC field 
strength of on-duty physicians was 296 family physicians; 108 
pediatricians, and 56 obstetricians/gynecologists, out of a total 
of 1,253 providers. 

Reducing Low Birth Weight and Infant Mortality. The 

BPHC has expanded its efforts to improve pregnancy out- 
comes for the relatively high-risk populations served by 
C/MHCs. Congress appropriated $32 million in FY 1990, and 
S34 million in 1991 to enable C/MHCs to undertake a com- 
prehensive perinatal care program that emphasizes the provi- 
sion of improved and expanded maternal, infant, and child 
health services. In FY 1992, additional Federal dollars totaling 
almost $10 million were directly appropriated for the Infant 
Mortality Reduction Initiative in C/MHCs to expand Com- 
prehensive Perinatal Care Program activities. 

Substance Abuse. The BPHC is working to meet the 
Healthy People 2000 objectives targeting the misuse of 
drugs and alcohol. In FY 1992, 15 primary care and drug 
treatment agencies were funded to link primary care services 
with drug abuse treatment to improve the effectiveness of 
drug treatment and to slow the transmission of HIV. Preven- 
tion activities include (1) increasing the awareness of primary 
care providers of the importance of screening for drug use and 



providing counseling and referral as needed, (2) participating 
in drug treatment and MDS prevention networks that include 
representatives from community agencies, (3) providing sub- 
stance abuse education programs to pregnant mothers, par- 
ents and adolescents, (4) disseminating culturally relevant sub- 
stance abuse prevention materials, and (5) providing primary 
care services to substance users and their families. Over the 3 
years of this demonstration program, services have been pro- 
vided to over 25,000 individuals. 

The Homeless. The Health Care for the Homeless Program 
is designed to stimulate local public and private agencies to in- 
crease their efforts to improve the health status of homeless 
persons and to increase coordination with other programs as- 
sisting the homeless population. In FY 1993, BPHC awarded 
grants to support 119 community-based organizations and 
coalitions providing primary health care, substance abuse, and 
mental health services to homeless families and individuals. Of 
the 119 grantees (including 9 new programs), 59 were 
C/MHCs. Several C/MHCs were included in community 
coalitions developed by the remaining 60 grantees. The 19 
Robert Wood Johnson/PEW Foundation projects that pro- 
vided the health care model incorporated in the Stewart B. 
McKinney Act of 1987, the authorizing legislation for the es- 
tablishment of BPHC's program for the homeless, also were 
included. 

Homeless Children. Health Care Services for Homeless 
Children, Section 340(s), was funded in FY 1993. Ten 
grantees were awarded funds to carry out demonstration pro- 
grams to provide for the delivery of comprehensive primary 
health care services to homeless children and to children at 
imminent risk of homelessness. 

Public Housing. The Public Housing Primary Care Program 
centers involve community residents in the planning, organi- 
zation, operation, and implementation of services and pro- 
grams designed to improve the health status of more than 
100,000 residents of public housing areas. Under the authority 
of the 1990 Disadvantaged Minority Health Improvement 
Act, which initiated the Section 340A Health Services for Res- 
idents of Public Housing Program, some 3.5 million residents 
in 1.4 million public housing units are potentially eligible. 

In FY 1992, BPHC awarded grants to support 14 organiza- 
tions and coalitions providing primary health care. Of the 14 
grantees (7 new starts), 8 are administered through Section 
330 Community Health Centers, 2 are with established Sec- 
tion 340 Health Care for the Homeless projects, 1 is operated 
through a county health department, 2 are nonprofit commu- 
nity-based organizations, and 1 is a hospital-based program. 

HIV and Other Sexually Transmitted Diseases. The 
BPHC continues to expand its efforts to provide comprehen- 
sive primary care services to population groups at high-risk for 
HIV infection and other sexually transmitted diseases. BPHC 
is funding community-based organizations under Title 111(b) 
of the Ryan White CARE Act to provide HIV early interven- 
tion services to those identified as being at risk for or having 
HIV infection. Services include HIV counseling, testing, part- 
ner notification, and the diagnostic evaluation (including for 
other sexually transmitted diseases) of those persons found to 
be HlV-seropositive. Through comprehensive agreements 



Prevention '93/94: Federal Programs and Progress 



with the Centers for Disease Control and Prevention, BPHC 
is conducting a demonstration program to incorporate 111V 
and STD prevention and treatment into primary care sues 
that are the usual sources of care tor the target populations. In 
placing selected health care providers, the N'llSC is targeting 
locations with a high incidence of AIDS and 1 HV-scropositiv- 
iiv that have demonstrated an inability to recruit physicians 
and other health personnel. Through its C/MHCs, BPHC is 
expanding the capacity of the health systems in underserved 
communities to respond to the spread of 1 I1V infection and 
other sexually transmitted diseases. 

Preceptorship Program. Since 1985, BPHC has supported a 
preceptorship program for medical students in C/MHCs 
through a contract with the American Medical Student \sso 
ciation. More than 4(H) students have been placed, and an ad- 
ditional 175 students will he matched annually over the next 3 
years. Thee students are employed to augment health pro- 
motion and disease prevention activities. The program ex- 
poses students to the challenges and opportunities of commu- 
nity primary health care and introduces them to the concepts 
of prevention and the health care needs of medically under- 
served people. 

Training Activities. BP] l( ! has offered and supported several 
long-term training opportunities lor health professionals cur- 
rently assigned in the N'llSC. including didactic/work experi- 
ence with CDC's Epidemic Intelligence service, extramural 
training leading to a Master of Public 1 lealth degree in mater- 
nal and child health, and Migrant Health Centers residency 
assignments in State health agencies. The program also pro- 
vides an opportunity for Nl ISC l'l IS dental officers to re- 
ceive experience in the operation of State-level denial pro- 
grams. It contributes to the development of a cadre of 
well-qualified public health dentists to support national fluori- 
dation and oral health objectives. 

BPHC also has entered into a cooperative effort with the 
Uniformed Services University o( the I lealth Sciences to pro- 
vide residency training in occupational medicine. It provides 
an opportunity tor PI IS physicians to receive the formal 
training necessary to become certified in occupational medi- 
cine. Long-term training was also made available to l'l IS 
nurses to provide training as nurse practitioners and nurse 
midwives. 

Clinical Support Strategy (CSS). CSS advances XI ISC sup- 
port of BPHC efforts through workshops and inservice con- 
ferences. XI ISC staff disseminate die latest information on i 1 1 
quality assurance. (2) dental disease prevention. I J) clinical is- 
sues in perinatal care. (4) sexually transmitted diseases, partic- 
ularly AIDS. (5) clinical issues in hypertension, (6) substance 
abuse in the primary care deliver, system, (7) occupational 
health and safety, (8) advanced trauma life support, (9) AIDS 
education and training, (10) health promotion for the elderly, 
(11) recognizing and addressing family violence and child 
abuse, (12) malpractice issues, and (13) advanced clinical skills. 

Federal Occupational Health Program. The Division of 
Federal Occupational Health (FOH) develops standards and 
criteria for occupational health programs. It offers consultant 
services to Federal managers to assure that employee and 
workplace health factors that increase productivity and de- 



crease liability are addressed. Occupational health program 
consultants are available on a reimbursable basis to assist fed- 
eral managers in defining, planning, implementing, and evalu- 
ating all aspects ol their occupational health programs. The 
lull operates 220 occupational health service centers 
throughout the United States. In 1992, it provided over $51 
million of reimbursable occupational health consultation and 
services addressing a wide scope of issues and concerns, e.g., 
environmental monitoring, hazard control, medical surveil- 
lance, wellness-fitness, employee assistance, substance abuse, 
disability management, and medical information. 



Maternal and Child Health 
Bureau (mchb) 

The Maternal and Child Health bureau is the principal 
Federal locus lor the planning, implementation, and oversight 
of national MCI 1 activities. 'The MCI II! administers 'Title Y 
ol the Social Security Act, which includes a program ot block 
grants to States to enable them to provide quality health care 
services to mothers, adolescents, and children. 'The program 
emphasizes provision anil improvement of services to low-in- 
come populations that otherwise would have limited access to 
such services. Title V also provides funds for two programs of 
discretionary grants and contracts: the Special Projects of Re- 
gional and National Significance (SPR \\Y> program and the 
Community Integrated Services Sv stems (CISS). The MCHB 
5PR \XS to provide leadership by Stimulating innovative 
approaches and developing new resources in the MCH areas 
ol research, training, genetic disease screening, testing, coun- 
seling, referral, information dissemination, hemophilia diag- 
nosis and treatment, and projects aimed at improving health 
services for mothers, infants, children, anil children with spe- 
cial health care needs. The CISS focuses on the building of in- 
frastructure and systems at the community level. Additionally, 
the MCI IB administers a number of other non-Title V autho- 
rizations including: Pediatric Aids Demonstrations, Ryan 
White Title IV, Emergency Medical Services for Children, 
and 1 lealthy Start. 

MCHB Prevention Highlights 

Maternal and Child Health State Block Grants. The MCH 

State Block Crams provide States with funds to develop re- 
sources and an infrastructure to support the following types of 
health services: preventive measures to reduce infant mortality 
and prevent disease and permanent disability in infants, chil- 
dren, and youth; rehabilitation services tor children and youth 
with special health needs; medical, surgical and corrective ser- 
vices for diagnosis, hospitalization, and care of children with 
disabilities or with chronic illnesses; hemophilia treatment 
centers and genetic disease counseling and screening projects; 
research and training projects; and other MCH programs pro- 
posed by the States. 

Reducing Low Birth Weight and Infant Mortality. Despite 
improvements in maternal and child health and in reducing 
infant mortality, progress in addressing this problem has been 
slow. Infant mortality rates in certain geographic areas and for 
certain racial and ethnic groups, particularly blacks, substan- 



Agency Innovations 



tially exceed the national rate. There has been little change in 
other measures associated with increased risk of infant death, 
such as the incidence of low birth weight or access to prenatal 
care. Using SPRANS, MCHB continues to provide national 
leadership and focus toward improving pregnancy outcomes 
to coordinate Federal, State, and private efforts in infant mor- 
tality reduction. Areas of focus include a project with the 
American College of Obstetricians and Gynecologists to in- 
crease die availability and accessibility of obstetrician-gyne- 
cologists for inadequately served pregnant women; promoting 
nutrition education and services as part of primary care; man- 
aging chronic diseases and complications of childbearing, as 
necessary in specialty care; and expanding problem identifica- 
tion and problem solving at the community level through in- 
fant mortality review programs. 

Healthy Start Initiative. The Healthy Start initiative is a 
demonstration program focused in 15 urban and rural com- 
munities with infant mortality rates at least 1.5 times the na- 
tional average. The planning phase of Healthy Start was 
funded in FY 1992, and the operational phase began in July 
1992. The goal is to reduce infant mortality by 50 percent in 
selected high-risk areas in 5 years. Resources will be concen- 
trated where thev are needed most to mobilize and capitalize 
on the capacity of families and communities to address infant 
mortality in a comprehensive manner. 

An integral part of Healthy Start is a comprehensive evalua- 
tion and monitoring component. The program also includes a 
national information and education campaign to raise aware- 
ness of infant mortality and motivate early entry into precon- 
ception and prenatal care. A major feature of Healthy Start is 
the development of strong coalitions of local and State govern- 
ments, the private sector, schools, religious groups, and neigh- 
borhood and community-based organizations. Together, the 
Healthy Start projects and their community coalitions are 
working to develop effective, comprehensive health care and 
social and support services for women and their babies. 

Healthy Tomorrows Partnership. The Healthy Tomor- 
rows Partnership for Children Program (HTPCP) is a 
SPRANS initiative that has been developed by MCHB in col- 
laboration with the American Academy of Pediatrics to stimu- 
late innovative children's health care efforts at the community 
level. HTPCP will assist children and their families in achiev- 
ing their full developmental potential through a community- 
based partnership of pediatric resources and community lead- 
ers. The initiative is designed to improve access to quality 
health care for the Nation's medically needy women, infants, 
children, adolescents, and children with special health care 
needs (disabilities) and to reduce the long-term cost of care 
through health promotion, disease prevention, and early in- 
tervention techniques. 

Demonstration Projects for Pregnant and Postpartum 
Women and Their Infants. Increasing attention in recent 
years has been focused on both the medical and non-medical 
problems relating to alcohol and other drug use among 
women of childbearing age. To avoid duplication of effort and 
concentrate limited resources to maximize their impact, the 
Center for Substance Abuse Prevention (CSAP) of SAMHSA, 
and MCHB (through SPRANS), have for the past 3 years 
jointly funded this demonstration program. 



Through a series of interagency agreements that have 
pooled program appropriations, personnel, and related exper- 
tise, a cooperative network of 144 service demonstration pro- 
jects, supported by regionalized research and information cen- 
ters, has evolved. The demonstration projects have developed 
more effective and comprehensive treatment interventions for 
women of childbearing age who use or are at risk for abusing 
alcohol, tobacco or other drugs. Several projects have directed 
special attention to the needs of intravenous drug users and 
the severe health consequences of shared needles (i.e., 
HIV/ AIDS and hepatitis infections). 

Community Integrated Service Systems (CISS). An expan- 
sion of the one-stop shopping initiative has been incorporated 
as part of the Community Integrated Service System (CISS) 
program, a new set-aside activity that was legislatively man- 
dated by OBRA '89 and activated when Title V annual appro- 
priations exceeded $600 million during FY 1992. The CISS 
program seeks to reduce infant mortality and improve the 
health of mothers and children, including those living in rural 
areas and those having special health care needs. This pro- 
gram is designed to complement the Federal Healthy Start 
initiative and State system development efforts by making 
funds available for services integration through use of one or 
more of six specified strategies that focus on home visiting ac- 
tivities; provider participation in publicly funded programs; 
one-stop shopping service integration projects; not-for-profit 
hospitals, community-based initiatives; maternal and child 
health projects serving rural populations; and less restrictive 
alternatives (including day care services) to inpatient institu- 
tional care for children with special health care needs. Four- 
year awards were made to 32 projects during FY 1992, a ma- 
jority of which focused on home visiting activities and 
one-stop shopping services integration. 

Child Health System Grants. MCHB is also funding a num- 
ber of multi-year SPRANS grants to foster the development 
of family-centered, coordinated, culturally competent, com- 
prehensive systems of primary health care and related services 
for all children within a designated age range and who live in a 
defined community. These grants aim to assist communities 
to combine public and private resources into coordinated sys- 
tems that assure all families access to comprehensive services 
and continuity of care for their children. 

Pediatrics AIDS. The Pediatric AIDS Health Care Demon- 
stration grants were awarded for the first time in 1988. There 
are currently 45 projects funded in 18 States, the District of 
Columbia, and Puerto Rico that seek to demonstrate more ef- 
fective ways to prevent infection, especially through perinatal 
transmission. In addition, the grants support the development 
of community-based, family-centered, coordinated services 
for HIV-infected infants, children, adolescents, and their fam- 
ilies. The Pediatrics AIDS Demonstration projects also aim to 
develop programs to reduce the spread of HIV infection to 
vulnerable populations, especially adolescents and minorities. 

Health and Safety in Child Care Settings. In 1987, a collabo- 
rative project, developed by APHA and AAP, was funded by 
MCHB to develop the document Curing for Our Children — Na- 
tional Health and Safety Performance Standards; Guidelines for Out- 
of-Home Child Care Programs. The standards represent the con- 



© 



Prevention '93/'94: Federal Programs and Progress 



sensus of many people regarding good practice in child care. 
The standards should be used to plan and to establish a quality 
program of child care. They have been distributed to all State 
health and licensing departments and key child care agencies 
and programs. MCHB has awarded 5 grants that support 10 
States in implementing these standards and in establishing a 
National Resource Center lor Health and Safety in Child 
Care at the National Center tor Education in Maternal and 
Child Health, Georgetown University. The mission of the 
Center is to support State health and licensing agencies, child 
care providers, child care health professionals, parents, and 
child advocates in their efforts to promote health and safety in 
child care settings. 

Minority Adolescent Health Program. MCHB has estab- 
lished a program to address critical health issues that place mi- 
nority children and youth at high risk for persistent school 
failure, familial estrangement, injury, violence, homicide, 
stress related illness, and other psychosocial problems. The 
Bureau's Adolescent Health Program was developed following 
a number of conferences convened during 1990 anil 199] to 
examine the relationship between morbidin mortality, health 
status, mm\ the social and economic difficulties young African 
American males face. Its scope was subsequently broadened to 
permit the development of a specialized project to serve incar- 
cerated minority females, their infants and children. 

five SPRANS grants have been funded to develop, imple- 
ment, expand. .uti.\ replicate institutional or community-based, 
comprehensive, primary care, preventive programs lor African 
American male children and adolescents .\nA incarcerated, 
young Hispanic and African American adolescent women. 
Each project has been awarded to an entity with linkages to a 
minority community and commitment to the special health 
needs ot minoritv youth. The projects stimulate development 
and use ot coalitions between communities, institutions ol 
higher learning, social service agencies, and health anil correc- 
tional facilities. 

Injun Prevention. VICHB has worked since l''" 1 ' to assist 
the States to develop and implement injury prevention inter- 
ventions. Thirty-three demonstration anil implementation 
grams have been awarded. In FY \'> l >2, six cooperative agree- 
ments were awarded called The Children's Safety Network, to 
provide technical assistance to States and others in child and 
adolescent injury prevention. Two are designated as core sites 
and address all aspects of child and adolescent injury preven- 
tion. The other four sites are issue-specific, covering rural in- 
jury prevention, third-party payor prevention efforts, adoles- 
cent violence prevention, and injury data. 

Emergency .Medical Services for Children. The Emer- 
gency Medical Services for Children (EMSC) grant program, 
which began in 1986. has funded 3 1 States tor implementation 
activities to improve the system of emergency care for chil- 
dren. Emergency care is viewed as a continuum that includes 
prevention, pre-hospital and hospital acute care, rehabilita- 
tion, and return to the community. As a result of this program, 
models have been developed for treatment and triage proto- 
cols, curricula for pre-hospital personnel first responders, 
emergency department staff, parents and caretakers, and stan- 
dards for designating specialized pediatric facilities and emer- 
gency departments with capacity for pediatric care. 



Bureau of Health Professions 
(BHPr) 

The Bureau ol Health Professions provides leadership to 
improve the training, distribution, utilization, and quality of 
personnel required to staff the Nation's health care delivery 
system. A number of 151 IPr grain programs provide support to 
educational programs for physicians, nurses, dentists, allied 
health personnel, health administrators, and public health 
professionals. High prioritj issues in health promotion and 
disease prevention are regularly targeted lor support. 

BHPr Prevention Highlights 

Health Education Training Centers (HETCs). Health ed- 
ucation and disease prevention are components of the Health 
Education and Training Center Program. A total of $3.8 mil- 
lion was awarded to support 1 5 HETCs in 12 States to en- 
courage health promotion and disease prevention in public 
health education and in the training of health professionals, al- 
lied health personnel, and community health workers. 

\ri.i Health Education Centers (AHECs). The Mil ( 
program employs educational swem incentives to attract and 
retain health care personnel in shortage areas. By linking the 
academic resources ol the university health science center 
with local planning, educational, and clinical resources, the 
AHEC program establishes a network of health-related insti- 
tutions to provide educational sen ices to students, faculty, and 
practitioners. In FY 1 (J '>2, five projects with health promotion 
and disease prevention components were awarded $343,790 
under AI IEC special initiatives. 

Education and Training Centers (ETCs). BHPr also sup- 
ports 1" regional \1I)S Education and Training Centers that 
educate health care professionals in prevention, tliagnosis, 
.uiA care of individuals with 111V infection. ETCs train pri- 
mary care providers to incorporate I 11V prevention strategies 
into their clinical practice, including diagnosis, counseling, 
and care of I [TV-infected persons and their families. 'Through 
short courses, clinical training, workshops, and teleconfer- 
ences and with videotape, computer-based, and printed mate- 
rials, ETCs provide health personnel with the latest informa- 
tion on IIIV care as well as referrals on complex problems. 
E'l ( !s serve 50 Slates, the I )isirul of Columbia, Puerto Rico, 
and the Virgin islands. In FY 1992, approximately $16.6 mil- 
lion was available to support ETC activities. 

Nurse Practitioner and Nurse-Midwifery Program. 

'There are 65 programs that prepare nurses for expanded 
roles in primary health care as family, pediatric, adult, geron- 
tological, women's health, obstetric/gynecological, occupa- 
tional health, and school nurse practitioners. Of these, 13 
focus on rural health care and 20 prepare nurse-midwives. 
The Advanced Nurse Education Program funded 17 projects 
to prepare nurses to focus on the prevention of illness and the 
promotion and restoration of health. The Special Project 
Grants Program funded 12 health promotion and disease pre- 
vention demonstration sites, including nursing primary care 
clinics, community-based centers, and nursing centers for the 
homeless. 



Agency Innovations 



Preventive Medicine Residency Program. In FY 1992, 13 

grants totaled approximately $1.6 million to medical and pub- 
lic health schools to provide partial support for 98 residents. 

Geriatric Education Center (GEC) grants. In FY 1992, 27 
programs were funded to encourage health professions' fac- 
ulty to include more geriatric content in basic and continuing 
professional education. In addition, 16 faculty training pro- 
jects in geriatric medicine and dentistry provide fellowship 
support for junior and mid-career faculty preparing for aca- 
demic careers in geriatrics. The 1992 Summer Geriatric Insti- 
tute of the Missouri Gateway GEC, for example, provided 3 
days of interdisciplinary programming for 350 health care 
professionals on the topic of Healthv Older People 2000. The 
Pacific GEC conducted a 1992 workshop for nurses on 
HEALTHY PEOPLE 2000 and the Oregon GEC had a summer 
1993 conference on health promotion and aging. The Stan- 
ford GEC, a pioneer in the area of ethnogeriatrics, addresses 
health conditions for which African American, Hispanic, 
Asian American, and Native American elders are at especially 
high risk. 

Mlied Health Project Grants. Since FY 1990, 28 grants 
were funded; 1 1 were newly funded in FY 1992. These grants 
are awarded to assist training institutions to develop curricu- 
lum units tor allied health training programs that emphasize 
knowledge and practice in the areas of prevention and health 
promotion, including the HEALTHY PEOPLE 2000 objectives. 
Approximately 50 percent of the grantees have also developed 
innovative models to identify and recruit minority and disad- 
vantaged students into the allied health professions. 

Public Health Special Projects Program. Of the 22 contin- 
uing Public Health Special Projects, 15 link academic and 
practice, 14 recruit minorities, 13 address public health occu- 
pational shortages (e.g., epidemiologist, environmental health 
professional), and 7 offer continuing education. 

Advanced General Dentistry Program. Emphasis is given to 
healdi promotion and preventive dentistry activities, targeted to 
special population groups that include the elderly and disabled. 

Ryan White HIV/ AIDS Dental Reimbursement Program. 

The program reimburses accredited dental schools and post- 
doctoral dental programs for the documented uncompensated 
costs thev have incurred for providing oral health treatment to 
HIV-infected patients. 

The Secretary's Award for Innovations in Health Promo- 
tion and Disease Prevention. In collaboration with the Fed- 
eration of Associations of Schools of the Health Professions 
and its member professional associations, the 10th annual 
competition, for the academic year 1992, called for innovative 
proposals to address one or more of the priorities outlined in 
Healthy People 2000. First prize was awarded to two York 
College of Pennsylvania nursing students for their proposal 
for "Breast Self-Examination for Visually Impaired Women." 
Two proposals tied for second place: "Cervical Cancer Pre- 
vention Project in the Inner City Communities of Roxbury 
and Jamaica Plain, Massachusetts" and "Teen Peer Out- 
reach/Street Work Project: HIV Prevention Education for 
Runaway and Homeless Youth." Third place in the contest 



was awarded to a proposal for "The Rush Prenatal Program at 
St. Basil's Free Peoples Clinic: Personal Learning and Devel- 
opment through Active Community Service." 

Eighth Report to the President and Congress on the Sta- 
tus of Health Personnel in the United States. The report 
includes a section on the public health personnel needed for 
meeting the Healthy People 2000 objectives. 



Bureau of Health Resources 
Development (bhrd) 

The Bureau of Health Resources Development implements 
and administers Federal policy and programs for (1) providing 
uncompensated health care services to the medically indigent; 
(2) providing financial analysis and technical assistance for the 
modernization and replacement of needed health care facili- 
ties; (3) providing grants and contracts to increase the number 
of organ donors; (4) monitoring contracts for operation of the 
national organ procurement and transplantation network, and 
the scientific registry of transplant recipients; (5) providing 
emergency assistance to localities that are disproportionately 
affected by the HIV epidemic and to States for the delivery of 
essential services to individuals and families with HIV disease 
under Titles I and II of the Ryan White Comprehensive AIDS 
Resources Emergency (CARE) Act.; and (6) providing trauma 
care financial assistance to States to improve State plans for 
the provision of emergency services and to rural areas for re- 
search and demonstration projects to improve the availability 
and quality of emergency medical care. 

BHRD Prevention Highlights 

Organ Transplantation. The organ transplantation program 
supports a national organ procurement system to assure organ 
availability for patients needing transplants. This includes 
grants and contracts to increase the rates of organ donation, a 
contract for the Organ Procurement and Transplantation 
Network patient registration data base used to allocate organs 
as they become available, and a contract for a Scientific Reg- 
istry for Transplant Recipients, which is a registry of demo- 
graphic and clinical information on all transplant recipients. 
In FY 1992, grants totaling $401,000 were awarded to support 
such activities as: educating black clergy about organ donation 
and transplantation; increasing the awareness of organ dona- 
tion among health professional students; and identifying 
physician and family factors that influence the consent process 
in pediatric organ donation. In FY 1993, the focus of the pro- 
gram shifted to research projects that can lead to gains in 
organ donation. The Bureau anticipates awarding 4 to 5 
grants totaling approximately $350,000. 

Studies on organ transplantation have shown that African 
Americans wait longer for organs than white Americans. A 
contract for a study entitled "Reasons African Anerican and 
White Waiting List Patients Are Unavailable for an Organ 
Offer" will be awarded in the 4th quarter of FY 1993 to deter- 
mine the extent of the problem and to develop solutions. 

Trauma Care. The Trauma Care Systems Planning and De- 
velopment Act of 1990, Title XII of the Public Health Service 



Prevention '93/'94: Federal Programs and Progress 



Act, authorizes .1 grant program to States for the develop- 
ment, implementation, and improvement of trauma care sys- 
tems. The Vet also establishes a grant program to rural areas 
for the improvement of trauma sen ices, and provided for the 
creation of .1 National Advisory Council on Trauma Care 
Systems. \ draft Model Trauma Care Systems Plan has been 
developed for use by States as a guide in the development ol 
their own trauma care plans. The plan identifies 14 required 
components of a trauma care system, and establishes the con- 
cept of an inclusive trauma care system, which matches the 
resources of trauma care providers to the needs o! injured 
patients. 

In FY 1992, 2.^ State projects were awarded $3.9 million in 
grants for trauma care planning activities. Five rural projects 
totaling S4S",400 were also hmd^A in TV 1992. A violence 
prevention initiative contract was funded to evaluate the im- 
pact ot a program to teach seventh graders in the Washington. 
DC school system about alternatives to violent behaviors. T\ 
L993 funding will include State grants at a level ot S3. 46 mil- 
lion, and rural project funding at S432.600. 

II1Y Services. I itles I .md 11 of the Ryan White Comprehen- 
sive VIDS Resources Emergency (CARE) Vctol 1990 provide 
emergency assistance to localities disproportionately affected 
bv the 111V epidemic (2,000 or more reported AIDS cases) 
and financial assistance to States or other public or private 
nonprofit entities tor the deliver) of services to individuals and 
families with 1 I1V disease. 

The Title I Ryan White CAR] \n requires grant recipient 
cities to address barriers to 111V health care services tor sev- 
eral special populations, including lmv men ot color. During 
1993, the grantees will plan programs to reduce these barriers 
ami report in their continuation application. In FY 1992, 
S214.6 million was awarded to implement Titles 1 and II ot' 
the CART Act. Under Title 1. SI 19.4 million was awarded in 
TV 1992 to IS eligible metropolitan areas (EiYIAs). Approxi- 
mately "4 percent of the funds were used to support four 
major program areas: primary care, support services, case 
management, and AIDS drug treatments. In FY 1993, S184.8 
million was awarded to 25 I'M Vs. 

Under Title II. S95.1 million was awarded to the Stares and 
I .S. Territories in I \ 1992. States and Territories were in- 
volved in the following 4 authorized program areas: 41 sup- 
ported HIV care consortia; 54 provided AIDS/HIV drug 
treatments. 25 supported home and community-based care, 
and 16 allocated funds for the continuation ot health insur- 
ance coverage. In FY 1993, SI 1 5.3 million was awarded to 
States and U.S. Territories. 

Up to 10 percent of the Title II funds is set aside for Spe- 
cial Projects ot National Significance (SPNS), which con- 
tribute to the advancement of knowledge and skills in the de- 
livery ot health and support services to persons with HIV 
infection. In FY 1992, $5.7 million was awarded for 26 SPXS 
continuation grants to State, local, or tribal health, mental 
health, or substance abuse departments; public or private hos- 
pitals; community-based service organizations; institutions of 
higher education; and national organizations for service 
providers. Grant awards are based on the need to assess the 
effectiveness of a particular model of care, the innovative na- 
ture of the project, and the project's potential to be repli- 
cated. In FY 1993, S5.5 million was awarded for 25 SPXS 



continuation grants. Approximately $750,000 will be awarded 
to 4 to 6 new projects focusing on care tor adolescents at high 
risk ot 1 IIV infection. 



Office of Rural Health Policy 
(orhp) 

The Office ot Rural Health Policy coordinates rural health 
research activities within 1)1 II IS .111. 1 administers a grant pro- 
gram lor Rural Health Research Centers, which collect infor- 
mation and conduct applied research on rural health care is- 
sues. The Office also administers grant programs supporting 
the development of State offices of rural health and outreach 
grant programs. In addition, the Office advises the Secretary 
on how the Medicare and Medicaid programs affect access in 
health care tor rural populations. 

ORHP Prevention Highlights 

Rural Health Outreach Program. In 1991, the lust 100 
Rural Health Outreach Demonstration Grants were awarded 
to rural communities with innovative new strategies for deliv- 
ering essential health care services. In 1992, an additional 27 
new grants were awarded. Under this program, grantees form 
partnerships or consortia with other local institutions, such as 
public health departments, hospitals, tribal organizations, or 
schools, to reach residents in need ol health care. Grantees arc- 
awarded up to i years ol funding. The program allows rural 
communities the latitude to create tailored solutions to their 
health care problems. Some projects have delivered preventive 
care to children 111 schools, Others have used telecommunica- 
tions to bring mental health services to isolated areas, and still 
others have supported rural EMS teams with additional train- 
ing ami equipment. 



Indian Health 
Service (ihs) 



The Indian Health Service assists Indian tribes in develop- 
ing the capacity to stall and manage health programs for 
American Indians (AI) and Alaska Natives (AN) through activ- 
ities that include health and management training, technical 
assistance, and human resource development. It also helps In- 
dian tribes to coordinate health planning; obtain and use 
health resources available through federal, State, and local 
programs; design and operate comprehensive health care ser- 
vices, including hospital and ambulatory medical care and pre- 
ventive and rehabilitative services; and develop community 
sanitation facilities for American Indians. 

IHS provides health care for approximately 1.8 million 
American Indians and Alaska Natives through a network of 43 
hospitals, 66 health centers, 4 school health centers, and more 
than 51 health stations and other treatment locations. The 
tribal health delivery systems administered by tribes and tribal 
groups, under contracts with IHS, operate 58 service units, 7 
hospitals, 89 health centers, 3 school health centers, and 237 



Agency Innovations 



smaller health stations and Alaska village clinics. IHS empha- 
sizes prevention through research, dissemination of informa- 
tion, and delivery of preventive services. The most dramatic 
evidence of the impact of these efforts has been an increase in 
expected lifespan for Indians of both sexes. Life expectancy at 
birth for American Indians has increased from 51 years in 
1939-1941 to 71.1 years in 1979-1981. However, M/AN life 
expectancy is still 3.3 years less than the 1980 figure of 74.4 
for the U.S. white population. 

Each IHS area office has developed health promotion/dis- 
ease prevention objectives. In FY 1991, IHS began including 
the HEALTHY People 2000 objectives in its organizational 
framework. 

Another innovation that underscores IHS's commitment to 
prevention is the strategic use of health indicators in the allo- 
cation of resources to support programs. The current alloca- 
tion strategy employs years of potential life lost as a crucial 
variable in assessing regional resource requirements. The 
funds apportioned under this method are targeted at the pre- 
vention of those diseases contributing most to the years of po- 
tential life lost in a given population. 

Highlighted below are various broad-scale prevention ef- 
forts. Not listed are the multitude of unique communitv- 
based efforts in fitness, mental health, nutrition, education, 
and geriatric prevention efforts. Indeed, IHS experience re- 
veals that the strength in prevention efforts rests with com- 
munity energy in identifying and addressing local prevention 
needs. 

IHS Prevention Highlights 

Maternal and Child Health Activities. Maternal anil Child 
Health (MCH) Program activities in IHS have an impact on a 
major proportion of the AI/AN population. Approximately 44 
percent of the AI/AN population is under 20 years of age and 
13 percent are women of childbearing age. IHS MCH activi- 
ties include women's preventive health sendees, perinatal 
health care, prenatal/post partum care, and health care ser- 
vices for infants and children. 

The IHS MCH program has successfully used medical 
technology in remote settings, built effective systems for safe 
water supply and waste disposal, and used vaccines and antibi- 
otics to prevent diseases. 

For the past 10 years, M/AN maternal mortality has 
changed very little and continues to be above the U.S. all 
races rate. Approximately 20 percent of M/AN births are to 
women less than 20 years of age. Based on studies conducted 
in selected IHS areas, fetal alcohol syndrome (FAS) appears 
to be well above the rates estimated for other populations in 
the United States. Other MCH health issues include family 
dysfunction leading to child abuse and neglect and adoles- 
cent risk behaviors resulting in alcohol and substance abuse, 
premature sexual activity, and intentional and unintentional 
injuries. 

The IHS MCH program is challenged by these complex 
health issues and gives special attention to the development of 
the following program activities: 

Immunization. IHS continues with an immunization initiative 
that maintains an immunization level of 85 to 90 percent 
among M/AN children age 3 to 27 months. Efforts are being 
made to expand the immunization initiative to include new 



vaccines, Haemophilus influenzae type B and hepatitis B, and a 
second dose of measles vaccine, as well as expanding immu- 
nization surveillance of older children. 

liifiint Mortality Reduction. In collaboration with the American 
Academy of Pediatrics and other Federal agencies, studies of 
the epidemiology and risk factors of SIDS among American 
Indians and Native Alaskan are also being initiated. 

Fetal Alcohol Syndrome. IHS funds FAS prevention research ac- 
tivities at the University of Washington. Through an intera- 
gency agreement with CDC, IHS collaborates in establishing 
FAS surveillance in several high-risk IHS areas. To increase 
levels of community and professional awareness and expertise, 
IHS established a technical assistance and consultation team 
in its Headquarters- West office. 

Child Abuse and Neglect. IHS collaborates with the Bureau of 
Indian Affairs (BIA) in the establishment of multidisciplinary 
child protection teams in each IHS area and service unit. At 
the headquarters level, IHS and BIA cooperate in the develop- 
ment and implementation of child abuse policy and tribal 
leadership and professional training programs. Recent Indian 
Child Protection legislation, Public Law 101- 630, Title IV, 
establishes a Child Abuse Treatment Grant Program that will 
be administered by IHS. 

Adolescent Health. IHS funds 14 tribal grants for community- 
based, school-associated teen centers. These centers provide a 
variety of health promotion and disease prevention services 
that are environmentally suitable to the unique needs of ado- 
lescents. The ultimate indicators of the success of these pro- 
grams will be higher self-esteem and fewer risk-taking behav- 
iors among the teens being served by these programs. 

Children With Special Needs. The IHS MCH program also pro- 
vides direction for two special programs: the Indian Chil- 
dren's Program, a program for children with disabilities and 
developmental delay, and the Head Start Intra-agency Agree- 
ment, a program that provides medical, nutritional, dental, 
and mental health technical assistance to Indian Head Start 
Programs. 

Community Injury Control. The injury prevention program 
in IHS Health has expanded considerably. Public awareness of 
the program grew with the 8th Annual American Indian and 
Alaska Native Injury Campaign, which was conducted during 
FY 1990. IHS initiated an injury prevention fellowship in FY 
1987. Over 75 fellows have graduated from this program. The 
focus of the program is to develop specialists in this area and 
to promote community analysis and prevention in injury pre- 
vention programming. Each fellow works with a community 
project during training. 

Injury prevention continues to be a part of the IHS promo- 
tion/disease prevention goals; through outreach to other 
agencies, a variety of injury control activities have been 
funded. Of particular interest is an interagency agreement 
with CDC that was negotiated in August 1985. The purpose 
of this agreement is to develop model community-based in- 
jury control programs in sites around Indian reservations. 
Major progress has been identified in surveillance and pro- 
gram intervention through this agreement. 



Prevention '93/94: Federal Programs and Progress 



Smoke-Free Environments. II IS has been a PUS role model 
in the establishment of smoke-free environments. A major 11 IS 
health target in FY 1986 was the establishment of smoke-free 
environments. Since then, all HIS hospitals, clinics, and offices 
have become smoke-free. In addition, the 11 IS Alcohol and Sub- 
stance Abuse Branch has mandated that all 11 lS-hinded sub- 
stance abuse facilities will be tobacco-free (i.e.. the exclusion ot 
cigarette smoking and tobacco chewing) by January 1993. These 
efforts have received support anil recognition from a variety ot 
national entities, including the American Cancer Society, the 
American Lung Association, and the National Cancer Institute. 

Health Education. 11 IS continues working with CDC ami 
State education agencies to develop the capacity for Indian 
schools and communitv -based school boards to promote com- 
prehensive school health education. The Health Education 
Program maintains and coordinates a comprehensive school 
health education project, which includes information on 
lll\ \1DS. smokeless tobacco, nutrition, exercise, feelings, 

and communication. 

Fluoridation and Other Oral Health Activities. During 
each year since 1982, the number and proportion of water s\ S 
tems needing fluoridation, having equipment installed, and re- 
porting fluoridation activity has steadily increased. In l l, sJ. 
there were 51 community water systems serving Indian com- 
munities that adjusted fluoride to optimum levels. In 1990, 
there were 435 community water systems that had optimum 
fluoridation. While 11 IS has placed a high priority on enhanc- 
ing efforts in community anil school water fluoridation, there 
are locations where II IS has encouraged the use of supple- 
mental fluoride tablets or drops and the initiation of school- 
based fluoride mouth rinse programs .is adjuncts to or as a 
next-best substitute for community water fluoridation. Clini- 
cally based dental caries preventive efforts have focused on 
dental sealants. 

In 1984, intervention efforts were begun to reduce the 
prevalence of baby bottle tooth decay, a condition that affects 
5(1 percent of Indian children. This national interdisciplinary 
campaign targets the caretakers of young children, since only 
by their actions can baby bottle tooth decaj be prevented. 

High smokeless tobacco use among Indian youths and ado- 
lescents is currently being addressed through a numl 
jointly sponsored II IS and State programs to prevent the initi- 
ation ot smokeless tobaCCO use and to promote the cessation 
among users. In January 1991, HIS began to develop and test 
teaching materials to prevent the use of smokeless tobacco in 
Alaska Native youth. Once the materials are developed and 
tested, thev will be used on a national basis. 

Because of the high prevalence of periodontal disease in 
the Native American population, the II IS Dental Program 
established a task force to review the problem and identify 
public health oriented solutions. A draft report of recom- 
mendations for implementing a periodontal prevention and 
control program with a public health approach is being cir- 
culated for comment. The dental program is also training a 
public health oriented periodontist who will coordinate the 
IHS periodontal disease prevention effort at the national 
level. 

In 1991. IHS began drafting a 5-year plan to guide the pro- 
gram toward the vear 2000 objectives during the period 
1991-1995. 



Substance Abuse Program. In 1978, the Indian Health Care 
Improvement Act required IHS to assume responsibility tor 
support ot Al/AN programs from NIAAA. Presently, II IS is 
funding over 560 Al/AN alcoholism programs serving Indian 
reservations and urban communities. Enhanced training ot 
health providers in earl) recognition and secondary preven- 
tion is a critical activitv ot the substance abuse effort. This 
training, undertaken in cooperation with NIAAA, is being 
provided through a primary provider training package in sub- 
stance abuse management and prevention. Ninety percent of 
[HS-funded tribal alcohol programs otter prevention services 
with .u\ emphasis on youth. 

The Secretary's initiatives on alcoholism and the Omnibus 
Drug \ci have stimulated a major expansion ot activitv in col- 
laboration with PI IS agencies. l!l \. and tribes. The Coordi- 
nated Discretionary Grant Programs ot PI IS agencies have 
been used to lund demonstration prevention projects in many 
Indian communities; HIS has funded 10 health 
promotion disease prevention projects and 2 health promo- 
tion evaluation projects; it also has provided training in alco- 
holism and substance abuse prevention to over v ()()() tribal, 
II IS. AtiA 1!1 \ personnel. Community-based alcohol and sub- 
stance abuse training sessions have been provided to over 
IS, (KM) participants, and over 57,000 students have partici- 
pated in school-based training. Six of the \2 IHS areas are 
currently operating residential treatment centers. The re- 
maining areas are providing contracted services to address this 
need. 



National Institutes of 
Health (nih) 



I he National Institutes ot Health administers a compre- 
hensive research program to improve the health of the 
American people through acquisition of new knowledge of 
disease. Nil I is a federation of institutes, centers, and divi- 
sions that includes 17 Institutes of Health, each with its own 
medical locus, and the National Library of Medicine, Clini- 
cal Center (a hospital research unit), and Fogarty Interna- 
tional Center. The N 1 1 1 Coordinating Committee for Dis- 
ease Prevention and Health Promotion provides the 
primary linkage between the Office of the Director, NIH, 
and the 1 7 institutes. It is also responsible for analyzing, co- 
ordinating, and identifying research opportunities in disease 
prevention and health promotion. NIH prevention research 
has as its objective both protection of people from disease 
and prevention ot the progression of disease to disability or 
early death. 

The NIH prevention activities are presented here by NIH 
component. .Although not mentioned specifically in this sum- 
man,- of activities, a number of the institutes support national 
information clearinghouses that serve as central resources for 
their specific components of health bv responding to requests 
for information and educational materials; several institutes 
organize consensus development conferences to enable health 
professionals to address new research findings; and all of the 
institutes publish information about their particular domain of 
health for both professionals and the public at large. 



Agency Innovations 



Fogarty International Center (fic) 

Programs of the Fogarty International Center (FIC) sup- 
port the international research components of the categorical 
institutes, as well as FIC's research and training program ac- 
tivities to foster and promote international cooperation in all 
fields of the biomedical and behavioral sciences. 

FIC Prevention Highlights 

Trans-NIH International Activities in Prevention. The 

FIC provides oversight of NIH participation in 83 bilateral 
agreements with 40 countries to foster biomedical and behav- 
ioral research cooperation that may include prevention and 
prevention-related activities. 

The FIC's regional initiatives in Central and Eastern Eu- 
rope (including the former Soviet Union) and Latin America 
and the Caribbean (LACI) continued to promote the develop- 
ment of new and expanded research collaboration between 
scientists in these regions and U.S. scientists. Under the 
LACI, FIC supported the initiation of new studies relevant to 
the prevention of diabetes, cystic fibrosis, cancer, and growth 
deficiencies in the Linked States and Chile. 

In FY 1992, FIC was redesignated for its third 5 -year period 
as the WHO Collaborating Center for Research and Training 
in Biomedicine. In this role, the FIC widely disseminates in- 
formation on opportunities for international collaboration in 
NIH prevention and other programs. 

Research Fellowship Programs. FIC supported the follow- 
ing prevention-related activities: 

• Working with scientists at the University of Cincinnati, 
a Fellow from Poland evaluated the effects of alcohol on 
hormone-stimulated growth in an animal model. The 
results indicated that alcohol administration to pregnant 
females depressed growth hormone and significantly 
lowers body and brain weight in the offspring when 
compared to controls. The inhibitory effects of ethanol 
on growth hormone-dependent development may play a 
role in growth retardation seen in children born to 
mothers who consume alcohol to excess; 

• Researchers at the Johns Hopkins School of Hygiene 
and Public Health, in collaboration with a Fellow from 
Helsinki, Finland, have shown that vaccination with He- 
mophilus influenza type B vaccine prevented meningitis 
in Navaho infants and children in Arizona. Vaccination 
reduced the number of healthy subjects who carried the 
bacteria in the throat. Such infant carriers are a potential 
source of transmission of infection to others; 

• Scientists at the University of North Carolina, in collabo- 
ration with a research fellow from the University of Lou- 
vain in Belgium, have begun to define the mechanism by 
which the body adapts to a diet low in total calories or 
protein. Using an animal model, their studies show that 
nutrients can affect the production, removal, and action of 
a protein factor that influences growth hormone. 

AIDS International Training and Research Program. In 

its first 4 years, FIC grants to 1 1 U.S. institutions, which then 
select participating scientists, provided training related to the 
understanding and control of AIDS to 500 health profession- 



als. The AITRP also provided more than 200 training courses 
for over 12,000 professionals to increase the number of skilled 
scientists in developing countries who can contribute to inter- 
national trials of candidate HIV/AIDS vaccines. 

The program also supported research in such key areas as 
pediatric AIDS, HIV infection among women, and new ways 
to prevent and treat AIDS-related opportunistic infections. 
Special efforts continue to be made by FIC to coordinate with 
NIAID-supported international AIDS research, particularly 
when related to vaccines. 

A Fogarty-trained graduate from the program at the Uni- 
versity of California — Los Angeles (UCLA) completed a study 
of the prevalence of HIV infection among new TB cases in 
Chiang Mai, Thailand. He demonstrated that TB is a major 
manifestation of HIV infection in Thailand, suggesting that it 
is appropriate to evaluate new cases of TB, especially in indi- 
viduals under 35 years of age, tor HIV infection. Fogarty 
trainees at University of California at Berkeley are studying 
the response to anti-TB therapy among HIV-infected and un- 
infected children with tuberculosis and the use of PPD skin 
tests to predict HIV infection in the Dominican Republic; an- 
other trainee is studying drug resistance patterns of M. Tuber- 
culosis recovered from AIDS patients in Brazil. 

A Fogarty post doctoral fellow from Zambia, working at the 
University of Miami, contributed critical data to an Interna- 
tional Registry of FflV-exposed Twins. This pioneering study 
involved 40 investigators from 9 countries and concluded that 
HIV-1 infection is more common in first compared to second 
born twins. The data indicate that a substantial proportion of 
HIV-1 transmission takes place during birth, which suggests 
that measures can be taken prior to birth to reduce the risk of 
HIV transmission from mother to child. 

Fogarty International Research Collaborative Awards. A 

study team from NIA and NCI visited Italy, Poland, and the 
Czech and Slovak Federal Republic to examine "Implications 
of Tumor Registry Data for Developing Etiologic and Clini- 
cal Insights on Aging and Cancer." 

The collaborative study was focused on individuation of the 
cardiac inotropic status by agency of the systolic time inter- 
vals. Its purpose was the development of methods and instru- 
mentation for accurate evaluation of sympathetic and vagal 
status in patients and normal individuals. Software was devel- 
oped to detect and measure R wave-carotid incisure interval at 
millisecond levels in clinical, psychophysiological, and exercise 
settings. This research will benefit cardiac patients and infants 
with respiratory sinus arrhythmia. 

The FIC supported two Russian scientists in a program 
dealing with prevention of infectious and non-infectious dis- 
eases, including MDS, tuberculosis, cancer, and heart disease. 

SchoIar-in-Residence. Projects included the development of 
methods to block nuclear penetration of viral DNA and pre- 
vent viral infections; the feasibility of gene therapy to amelio- 
rate or prevent the leukemia associated with Down syndrome; 
studies of the molecular basis of HIV pathogenesis as a rational 
basis for the prevention of AIDS; the development of a unique 
bacteriophage vector-based vaccine against AIDS; an evalua- 
tion of the ability of Mammary-Derived Growth Inhibitor to 
block the proliferation of breast cancer cells; and research on 
the transport of ions and water through ocular membranes and 
its relevance to the prevention and treatment of glaucoma. 



Q 



Prevention ' 9 3 / ' 9 4 : Federal Programs and Progress 



© 



National Cancer Institute (nci) 

The National Cancer Institute (NCI) conduce research on 
cancer prevention and control and the surveillance and moni- 
toring of the incidence, mortality, and morbidity of cancer. \ 
priority for NCI is the translation of the knowledge gained 
from its research into application through technology transfer 
and health promotion activities for the benefit ol the public. 
The goal of these efforts in general is to achieve significant re- 
ductions in cancer incidence, mortality, and morbidity with a 
concomitant increase in cancer survival. 



NCI Prevention Highlights 

( Ihemoprevention. The goal of chemoprevention is to inhibit 

or delay the onset of neoplasia through pharmacologic, nutri- 
tional, or endocrinologic intervention prior to the clinical ap- 
pearance "t a malignant lesion. .Vs such, chemoprevention pro- 
vides a useful complement to therapeutic modalities in current 
clinical use. and may he particularly useful in the control ol 
cancer in tissues tor which therapeutic intervention is relatively 
ineffective. Studies conducted in experimental animal models 
tor human cancer have demonstrated that carcinogenesis in a 
number oi tissues is subject to inhibition through the adminis- 
tration ot biological or chemical agents. Anticarcinogenic ac- 
tivity has been demonstrated tor a highly diverse group ol bio- 
logical and chemical agents, (i.e.. oltipraz, quinacrine). 
Research in chemoprevention includes laboratory and clinical 
studies ot chemoprevention agents, clinical nutrition studies, 
anil epidemiological studies. Three agent classes is significantly 
advanced in clinical trials and are considered the first genera- 
tion ot candidate chemoprev entiv e agents. These include the 
retinoids (natural anil synthetic analogues ot vitamin A), (nine 
studies), beta-carotene (seven studies), anil calcium compounds 
(three studies). In addition, a second generation ot six promis- 
ing new compounds are in Phase 1 trials. These are nons 
teroidai anti-inflammatory agents such as piroxicam and 
ibuprofen, antiparasitic agents such as oltipraz (a dithiolth- 
ione); inhibitors ol polyamine biosynthesis such as difluo- 
rmethylornithine, glycyrrhetinic acid, and N-acetylcysteine. 

Diet and Cancer. \( 1 is conducting a wide variety ot dietary 
studies. A randomized, double-blind clinical trial is evaluating 
the efficacy of the nutritional supplements beta-carotene, vita- 
min C, and vitamin E in preventing neoplastic polyps of the 
large bowel in persons at high risk for this condition. Another 
group of investigators has initiated a randomized trial to eval- 
uate the role of dietary fiber and calcium in subjects at ele- 
vated risk tor developing colon cancer. Other research studies 
are investigating the relationships between the carcinogenic 
process and steroid hormone metabolism, alcohol, dietary 
protein, and selenium. In addition. NCI is conducting a 3-year 
feasibility study to develop methods for achieving dietary- 
change among minority and less educated women. The overall 
goal of this program is to determine whether a low-fat dietary 
pattern, with a corresponding high level of fruit and vegetable 
intake, can decrease the incidence of cancer in post- 
menopausal women. To stimulate collaborative research be- 
tween nutritional science and basic and clinical research. NCI 
is sponsoring new interactive project grants for nutrition and 
cancer prevention. 



National S-A-Daj Program. I he National 5-A-Da) Pro- 
gram, designed to encourage Americans to cat five or more 
servings ot fruits and vegetables every day, was begun during 
FY 1992. This program is a joint project of the Ml and the 
Produce for Better Health Foundation (PBHF) and is the 
largest public/private enterprise ever undertaken In the N( T 
Over the next 5 years, the National 5-A-Day Program will en- 
courage all \meru .ins to cat live servings or more of fruits and 
vegetables a day as part of a low tat. high fiber diet; award 4- 
year research grants to evaluate the effect ol 5 \ Da) activi- 
ties m schools, workplaces, and other community settings; and 
work with TBI IT. which represents more than 200 food re- 
tailer organizations and more than 30,000 supermarkets, to 
promote the program's message in the marketplace. 

Smoking and Cancer. The Community Intervention Trial 
(COALVIl T 1 tor Smoking ( lessation is the largest smoking in- 
tervention study in the world, involving some 2 million peo- 
ple directly, and millions more indirect]) . The COMMIT de- 
sign involves 1 1 pairs ol communities in North America that 
are matched in size, demographics, and location. The pri- 
mary hypothesis being tested is that the implementation of a 
defined intervention protocol, delivered through multiple 
eonmnmilv groups mu\ organizations and using limited exter- 
nal resources, will result in a quit rale in heavy smokers at 
least 10 percentage points greater than that observed in com- 
parison communities. COMM1 T is serving as a major natural 
laboratory tor the study ot community-wide smoking cessa- 
tion and control efforts. The field work ot this trial was com- 
pleted in early 1993 ami is being followed by data analysis. 
On completion ot the trial, materials will be available through 
American Stop Smoking Intervention Sunk (ASSIST) for 
Cancer Prevention. 

\SS|S T represents a collaborative effort between NCI and 
the American Cancer Society, along with State and local 
health departments and other voluntary organizations to de- 
velop comprehensive tobacco control programs in 17 States. 
Its purpose is to demonstrate that the widespread, coordinated 
application of the best available strategies to prevent and con- 
trol tobacco use will significantly accelerate the current down- 
ward trend in smoking and tobacco use. Populations vv hose- 
smoking prevalence rates remain a problem will be targeted in 
ASSIST intervention sites. ASSIST is a community-based in- 
tervention directed by local voluntary coalitions that will plan 
and implement tobacco control activities in schools, worksites, 
anil other community channels. Specific interventions include 
training health care providers to deliver brief cessation coun- 
seling, implementing smoke-free policies in schools and work- 
sites, and enhancing media coverage of tobacco use issues. AS- 
MS 1 will reach 0] million Americans, including 18 million 
smokers. More than 4.5 million adults are expected to quit 
smoking and 2 million adolescents will be prevented from be- 
coming addicted. Overall, it is expected that 1.2 million pre- 
mature deaths will be averted, including 422,000 deaths from 
lung cancer. 

Worksite Studies. The workplace is an obvious channel for 
cancer control activities aimed both at reducing occupational 
exposures and modifying unhealthy lifestyle choices. Research 
is underway to explore the potential of the worksite to im- 
prove a broad set of cancer prevention and control behaviors. 
The Working Well cooperative agreement is a large, Phase 



Agency Innovations 



III project involving 4 research centers, a coordinating center, 
and 120 randomized worksites throughout the United States. 
The project is designed to determine whether effective work- 
site-based intervention methods to reduce tobacco use, 
achieve cancer preventive dietary modifications, increase 
screening prevalence, and reduce occupational exposures can 
be developed and implemented in a cost-effective manner. 
Smaller worksite-based projects will develop mechanisms to 
assist worksite wellness managers to choose appropriate can- 
cer control materials and develop interactive computer-based 
nutrition self-help programs. 

Screening Trial for Prostate, Lung, Colorectal, and Ovar- 
ian Cancers. In this 16-year randomized trial, 37,000 men 
will be screened for 4 years for prostate, lung, and colorectal 
cancers, and 37,000 women will be screened for the same pe- 
riod of time for lung, colorectal, and ovarian cancers. Equal 
numbers of men and women will be followed with routine 
medical care as controls. There will be a 10-year follow-up of 
both study subjects and controls to determine the effects of 
screening for those four cancer sites on mortality. Studies will 
be conducted using diagnostic biopsy specimens in relating 
genetic aberrations to these cancers. 

Breast Cancer Prevention Trial with Tamoxifen. The 

Breast Cancer Prevention Trial was implemented in 1992 by 
the National Surgical Adjuvant Breast and Bowel Project. The 
study is testing the ability of tamoxifen, an anti-estrogen med- 
ication used in post surgical treatment of early stage breast 
cancer, to prevent the development of breast cancer in women 
at increased risk for developing the disease. Based on results 
from treatment clinical trials in which tamoxifen reduced the 
incidence of breast cancer in the opposite breast in women al- 
ready diagnosed with breast cancer, scientists estimate that ta- 
moxifen has the potential to reduce the incidence rate ot 
breast cancer in high-risk women by at least 30 percent. Ap- 
proximately 16,000 women at increased risk for breast cancer 
due to age, family histoiy, and personal history (i.e., age at 
first birth, age at menarche, and previous breast biopsies) are 
being randomized to receive tamoxifen (20 mg/day) or 
placebo for an initial period of 5 years. The total trial will last 
10 years. 

Prostate Cancer Chemoprevention Trial with Finasteride 
(Proscar). A prostate cancer chemoprevention trial using fi- 
nasteride (Proscar) is planned as an intergroup study and will 
be implemented in the Community Clinical Oncology Pro- 
gram clinical trials network. Prostate cancer is influenced by 
androgens, particularly in its earliest stages of development. 
The proposed study will test the hypothesis that reduction of 
dihydrotestosterone (DHT) will prevent the development of 
prostate cancer. Finasteride is an inhibitor of DHT synthesis. 
Finasteride has an excellent toxicity profile and was recently 
approved by the FDA as an alternative to surgery in the man- 
agement of benign prostatic hyperplasia. The trial will involve 
15,000-20,000 men at risk for prostate cancer. Subjects are 
randomized to receive finasteride or placebo for up to 10 
years. The endpoint of the study will be diagnosis of clinically 
significant prostate cancer. 

Leadership Initiatives in Special Populations. The Na- 
tional Black Leadership Initiative on Cancer (NBLIC) was 



established to develop coalitions to promote NCI's cancer 
prevention and control goals, and stimulate the involvement 
of the African American community in this effort. Among 
the NBLIC's priorities are the promotion of smoking cessa- 
tion, diet modification, and early detection screening and 
treatment. The NBLIC has established over 50 cancer pre- 
vention and control coalitions which are helping to imple- 
ment collaborative efforts among local organizations, insti- 
tutions, and community leaders throughout the LJnited 
States. Through those coalitions, the NBLIC is encourag- 
ing breast cancer screenings as well as cancer and preven- 
tion control activities that link with national health promo- 
tion campaigns such as National Minority Cancer 
Awareness Week, and National Breast Cancer Awareness 
Month. 

The National Hispanic Leadership Initiative on Cancer 
(NHLIC) was initiated to develop a national outreach pro- 
gram that will address the cancer prevention and control 
needs within Hispanic communities through the establish- 
ment of cancer prevention and control coalitions; stimulate 
the involvement of Hispanic community leaders in Hispanic 
community cancer control coalitions; and develop and sup- 
port cancer control intervention outreach activities in His- 
panic communities throughout the United States and Puerto 
Rico. 

The Appalachia Leadership Initiative on Cancer (ALIC), 
although similar to the NBLIC and the NHLIC, is not race 
or ethnic group specific. Rather, ALIC is targeted to all per- 
sons, particularly those that are medically underserved, that 
reside in the region of the United States known as 
Appalachia. 

Cancer Control for Native Americans. Intervention re- 
search addressing the cancer problem in Native American 
(American Indian, Alaska Native, and Native Hawaiian) pop- 
ulations is seeking to identify and remedy key factors that 
contribute to avoidable mortality from specific cancer sites. 
The Urban Native American Women's Cancer Prevention 
Project is a study of cervical cancer prevention and treatment 
among Native American women living in eight metropolitan 
areas. The study will assess cancer prevention knowledge, at- 
titudes, and behaviors; develop culturally sensitive preven- 
tion/intervention strategies; and evaluate the effectiveness 
and efficacy of those strategies. The Prevention of Cervical 
Cancer in Native American Women is a health education re- 
search project focusing on cancer prevention among two pop- 
ulations of Native Americans, the Cherokee and the Lumbee. 
The major goal of the study is to increase screening and fol- 
low-up for cervical cancer prevention among women age 18 
and older who receive Pap smears at appropriate intervals and 
return for follow-up care when necessary. The Wai'anae 
Coast Cancer Control Project is testing the effectiveness of 
an integrated, community-driven, cancer control intervention 
as a means of increasing breast and cervical cancer screening 
practices among Native Hawaiian women. The Prevention of 
Cervical Cancer in Native Alaskan Women project is de- 
signed to reduce the morbidity and mortality from invasive 
cervical cancer in Alaska Native women. At the same time, 
Primary Prevention of Cancer in Native American Popula- 
tions is developing innovative tobacco use prevention or ces- 
sation intervention programs and determining their long- 
term effectiveness among Native Americans. 



Prevention '93/'94: Federal Programs and Progress 



National Center for Human 
Genome Research (nchgr) 

The Human Genome program is a worldwide research ef- 
fort that has the goal of analyzing the structure of human 
D\ \ and determining the location of the estimated 100,000 
human genes. In parallel with this effort, the DNA of a set of 
model organisms will be studied to provide the comparative 
information necessary for understanding the functioning ol 
the human genome. The Nil 1 and the Department of Energy 
are the key agencies managing this project in the United 
States. To coordinate this program at Nil I. the Offu 
Genome Research within the Office of the Director. Nlll. 
was created on October 1. 1 ( 'SS. One year later, the l Htlce was 
replaced with the National Center for Human Genome Re- 
search (NCHGR). 

The NCHGR plans genome project research goals for 
mapping anil sequencing the human genome, supports re- 
search and research training programs related to attaining 
these goals, coordinates with other U.S. and foreign agencies 
engaged in genome research, advises the Nil 1 director and se- 
nior staff ot the 131 II IS on progress in genome research, and 
communicates research advances to the public .uiA scientific 
community. 

In FY 1990, the NCHGR and the Department of Energy 
issued .1 joint research plan lor the first 5 years ol the Human 
Genome Project. Five-year goals have been identified lor the 
following areas, which together encompass the human 
genome project: 

• Mapping and Sequencing the 1 luman Genome 

• Mapping and Sequencing the Genome ol Model ( )rgan- 
isins 

• Data Collection and Distribution 

• Ethical, Legal, and Social Considerations 

• Research Training 

• Technology Development 

• Technology Transfer 

'This project will spawn new research role tools — chromo- 
some maps, DNA sequence information, laboratory technol- 
ogy, and computer data bases -that should form the founda- 
tion of 21st-century biomedical science. Knowledge gained 
from the genome project research will help scientists around 
the world to understand ami eventualh treat many of the 
more than 4.00(1 genetic diseases that afflict humans. Genome 
research will also shed light on the mechanisms of the many 
common but complex diseases, such as heart disease, hyper- 
tension, arthritis, cancer, and Alzheimer's disease, in which 
generic factors play an important role. Virtually even- compo- 
nent ot NIH supports genetic research ami the fruits ot 
NCHGR-Supported research are expected to facilitate and 
complement these efforts. 



National Center for Research 
Resources (ncrr) 

The National Center for Research Resources develops and 
supports critical research technologies for health-related re- 
search. NCRR supports shared resources, sophisticated in- 
strumentation and technology, animal models for studies of 



human disease, clinical research environments, and research 
capacity building tor underrepresented groups. 

NCRR Prevention Highlights 

Immiinogenctic Studies of African Americans. At the 
Human Immunogenetics Laboratory at Howard Universit) in 

\\ ashington. DO. scientists are exploring the relationships be- 
tween disease susceptibility and immunogenetic factors in the 
African American population. The researchers are character- 
izing human leukocyte antigens (HLA) anil genes that are as- 
sociated with diseases such as diabetes, arthritis, and cancer. 
They are also developing reagents ami technologies to belter 
characterize 111. A tvpes in minority populations. 

Ill \ tissue antigens are cell surface proteins that play a key 
role in determining whether an organ transplant will be ac- 
cepted or rejected by the recipient's body. Each individual 
possesses a unique combination ol lll.v antigens, m\i\ these 
proteins must be carefully matched between organ donor anil 
recipient to ensure long-term graft acceptance. 1 issue typing 
reagents are prepared largely from the blood sera ot white 
women who have had more than one baby and who, therefore, 
may have antibodies to the father's 111. A antigens. The 
Howard researchers have been collecting sera from black 
women, screening it for 1 II. A antibodies, and determining the 
specificit) of the antibodies. This is hoped to help increase the 
transplantation success in blacks. 

This research has led to the discovery of how the structure 
of a particular antigen puts one at risk for a given disease. 
The) have identified an antigen combination, DQw4, DR3, 
which is unique to the black population and is associated with 
resistance to type 1 diabetes. They have also explored the rela- 
tionship between the genetic makeup of blacks and whites and 
the risks of developing myeloma and breast cancer. 'The re- 
searchers are compiling a data base that contains information 
on the HLA antigens and genes associated with various dis 
eases in African Americans. 

I se of Monoclonal Antibody 60.3 to Prevent Hyperacute 

Cardiac Rejection. Hyperacute cardiac rejection is the un- 
fortunate sequela to cardiac transplantation performed in the 
presence ot cytotoxic antibodies in the host against the donor. 
Hyperacute rejection humoral immunity plays a dominant 
role, unlike in allograft acute rejection, where mononuclear 
cells play a prominent role. Histological examinations of the 
failed hyperacutely rejected allograft document the presence 
of leukocytes, platelets, and thrombi. Most commonly used 
immunosuppressive regimens are largely ineffective in pre- 
venting hyperacute rejection. Because of these limitations, re- 
searchers at the University of Washington Regional Primate 
Center are pursuing other lines of investigation to prevent hy- 
peracute rejection in sensitized recipients. They are evaluating 
whether monoclonal antibody 60.3 will be able to attenuate 
hvperacute rejection ot cardiac allografts when implanted into 
sensitized recipients. 

Measuring Vaccine Efficacy from Epidemics of Acute In- 
fectious Agents. Accurate estimation of field vaccine efficacy 
is important for designing and evaluating effective infectious 
disease intervention programs. This is particularly true for 
many acute viral diseases (e.g., measles, pertussis, influenza) 
for which vaccination remains the primary means of interven- 



Agency Innovations 



tdon. Researchers at Emory University have developed math- 
ematical models that estimate the field efficacy of vaccines. 
They have taken into consideration many epidemiological fac- 
tors including population structure, duration of the study, the 
fraction vaccinated, and reduction of exposure to infection 
through herd immunity. The researchers used VESPERS- 11 
(Virus Epidemic Simulation Programs for Epidemiological 
Research Studies) to carry out simulations of a measles epi- 
demic in a closed population. The simulations provided vac- 
cine efficacy estimations (0.354) extremely close to the actual 
value (0.0350). These models help researchers understand the 
spread of infectious diseases and help them to determine the 
most effective methods for preventing that spread. 

Low-Dose Estrogen May Reduce Post-Menopausal Car- 
diac Risks. Low-dose estrogen prescribed for women at 
menopause to prevent osteoporosis and relieve discomfort has 
the additional benefit of improving the balance of cholesterol- 
carrying lipoprotein in the blood. As a result it may help pro- 
tect older women against their increased risk of heart disease, 
according to researchers at Harvard Medical School and 
Brigham and Women's Hospital in Boston, Massachusetts. 

Based on clinical studies the Boston investigators found 
that both the low and the high estrogen doses decreased the 
average low-density lipoprotein (LDL) cholesterol by 15 and 
19 percent, respectively, and increased the "protective" high 
density lipoprotein (HDL) cholesterol level by 16 and 18 per- 
cent. Thus, lower doses of estrogen appear to be as effective 
as higher doses. Estrogen was also found to increase the pro- 
duction of very-low-density lipoproteins (VLDL) by the liver 
and its secretion into the blood. However, most of the addi- 
tional VLDL is apparently cleared directly from the blood 
without being converted to LDL. At the same time, the ca- 
tabolism, or breakdown, of LDL is stimulated so that the net 
result is a lower LDL blood concentration and a higher 
VLDL concentration. 

Throughout their lives, women have a lower incidence than 
men of cardiovascular disease, although the differences begin 
to narrow when women reach the 6th decade of life. The di- 
minished estrogen production in menopause and its effects on 
lipoprotein metabolism apparently push women toward the 
male risk level at that stage. This finding may encourage more 
women to take low-dose estrogen. Only 15 to 20 percent of 
post-menopausal women in the United States receive estrogen 
replacement therapy. 

Affluent Diet Increases Risk of Heart Disease. Over the 
past 25 years, the Oregon Health Sciences University has char- 
acterized the food and nutrient intakes of the Tarahumara In- 
dians in Chihuahua, Mexico, while simultaneously document- 
ing various aspects of their lipid metabolism. The 
Tarahumaras' agrarian diet consists primarily of pinto beans, 
tortillas, and pinole (a drink made of ground roasted corn 
mixed with cold water), with squash and gathered fruits and 
vegetables and small amounts of game, fish, and eggs. This 
diet, along with endurance racing, is probably the reason coro- 
nary heart disease is virtually non-existent in their culture. 

After 5 weeks of consuming the "affluent" diet, (dietary fat 
made up 40 percent of total calories — comparable to the holi- 
day diet of many Americans), the subjects' mean plasma cho- 
lesterol levels had increased by 31 percent, primarily in the 
LDL fraction, which rose 39 percent. HDL-cholesterol in- 



creased by 3 1 percent (therefore LDL to HDL ratios changed 
very little). Plasma triglyceride levels increased by 1 8 percent, 
and subjects averaged an 8-pound gain in weight. The lipid 
changes occurred surprisingly soon, yielding nearly the same 
results after 7 days of affluent diet as after 35 days. The overall 
implication of this study is that humans can readily move their 
plasma lipid and lipoprotein values into a high-risk range 
within a very short time by eating an affluent, excessive diet. 

Aerobic Fitness Affects the Diurnal Patterns of Blood 
Pressure in Adolescents, Particularly in Blacks. Earlier 
studies have shown that although black and white adults have 
similar blood pressure while awake, blacks have higher blood 
pressure during sleep. This difference in nocturnal blood 
pressure may account in part for the increased prevalence of 
hypertension among blacks, which is nearly 1.5 times higher 
than that among whites. 

To examine the relationships among race, fitness, and blood 
pressure in 10- to 18-year-olds, researchers at the University 
of Tennessee General Clinical Research Center at LeBonheur 
Children's Medical Center in Memphis, first analyzed ambu- 
latory blood pressure measurements to determine whether 
black adolescents had higher pressures during sleep than did 
white adolescents, then evaluated how aerobic fitness influ- 
enced this 24-hour rhythm of blood pressure. 

Both black and white children had comparable systolic and 
diastolic blood pressure while awake, but while asleep, black 
males had higher systolic levels and both black males and fe- 
males had higher diastolic levels. Subjects were then divided 
into "more-fit" and "less-fit" categories based on whether 
their maximal oxygen consumption during the exercise test 
tell above or below the median for their sex. In white children, 
awake or asleep, there were no differences in the blood pres- 
sures of less-fit and more-fit boys or girls. However, less-fit 
black children, awake or asleep, had consistently elevated sys- 
tolic blood pressure relative to that of more-fit black children 
and all white children. These differences could not be ac- 
counted for by height, weight or weight to height indexes. 
This study suggests that staying fit to keep blood pressure in 
check, thus reducing the risk of hypertension, appears to be 
more important for blacks than for whites. 

Screening Programs for Breast and Cervical Cancer. The 

Mnnesota Department of Health, in collaboration with the 
University of Minnesota at Twin Cities, is developing screen- 
ing and tracking programs for breast and cervical cancer in 
uninsured and under-insured women. Clinical sites, radiology 
departments, and pathology laboratories are providing data on 
test variability and response rates. Simulation studies will ex- 
amine the effect of different scheduling, tracking, and follow- 
up mechanisms in reducing morbidity and mortality in this 
population. 

Strategies to Interrupt Maternal-Fetal HrV Transmis- 
sion. Investigators at Baylor College of Medicine and Texas 
Children's Hospital have participated in national AIDS Clini- 
cal Trial Group (ACTG) protocols designed to prevent trans- 
mission of HIV from the mother to the fetus or neonate and 
to determine the role of the placenta in transmission. 

Based upon in vitro data and in vivo studies in adults, the re- 
combinant-hybrid molecule CD4-IgG has been proposed as a 
possible means of interrupting transplacental/perinatal transfer 



Prevention '93/94: Federal Programs and Progress 



© 



of HIV infection. In one study, HIV-infected pregnant women 
were tjiven CD4-IgG just prior ro delivery. The results show 
(1) about 1 percent of the rCD4-IgG given to mother is trans- 
ported across the placenta to infant; and (2) rCD4-IgG accu- 
mulates in the fetus when given 1 week prior to delivery. It is 
likely that giving mothers rCD4-IgG .it higher dosages (tip to 
6000 meg/kg possible) and up to 3 times weekly prior to birth 
will afford the fetus much higher and sustained blood levels of 
rCD4-IyG. It is possible that the unique use of rCD4-Ig< i « ill 
prevent perinatal transmission ol 1 1IV. 

In another study, based upon preliminary observations in 50 
placentas of 1 LTV-infected women, it is believed that HIV can 
be detected in the placental villi, generally in the fetal tro- 
phoblastic layer. Using in situ hybridization and confocal 
imaging microscopy, investigators have detected 1 ll\ -RN \ in 
fetal trophoblastic cells in almost all of those infants whi 
sequently were shown to have HIV infection by HIV culture 
and/or PCR technology, p24 Ag determination, and clinical 
symptoms. The researchers plan to examine JO placenta-, for 
HTV-RNA and to correlate the clinical outcome and HIV in- 
fection status in the infants horn to the subjects and to deter- 
mine in vitro the factors important in permitting HIV infec- 
tion of chorionic villus samples. 

AIDS/HIV among Intravenous Drug I sirs. Investigators at 
die New York University General Clinical Research Center 
statistically analyzed the incidence of AIDS in different HIV 
exposure groups. They found that fewer AIDS cases than ex- 
pected occurred among male homosexual subjects and adults 
widi hemophilia, while no important deviation from expected 
numbers ol cases occurred among intravenous drug users or 
persons infected from heterosexual contacts. Of 24 HIV sero- 
conversions. 22 occurred among persons who injected illicit 
drugs since their last interview. Among subjects who continued 
to inject drugs, heroin injection alone was a relatively unimpor- 
tant risk factor for I I1V seroconversion, being reported by only 
of the 22 persons who seroconverted; cocaine injection ap- 
peared to be more of a driving force in predicting HIV sero- 
conversions, female sex was found to be another significant 
predictor of seroconversion. N'one of the other risk factors ex- 
amined, including use of shooting galleries, cleaning of drug 
paraphernalia with bleach, sharing of paraphernalia with per- 
sons known to have developed AIDS, or number of male sexual 
partners, were found to be significant factors when gender and 
injection frequency were considered. Greater intravenous use 
of cocaine and receptive sexual intercourse with male drug 
users also may place drug-using women at increased risk of 
1 1IY infection compared to drug-using men. 

AIDS Education. A summer basketball camp established near a 
public housing project was used to dispense AIDS education to 
neighborhood youth. Pre- and post-tests, conducted by re- 
searchers at the Minority Clinical Research Center at Meharrv 
.Medical College, were used to measure the effectiveness of this 
innovative teaching program and a 9-month follow-up test is 
planned. This program serves as a model for the Epidemiol- 
ogy/Prevention Research Program of the Association of .Minor- 
ity Health Professions Schools (AMHPS) MDS Consortium. 

Physiologic Antioxidant Agents & Oxidative Modification 
of Low-Density Lipoproteins (LDL). In a recent study, in- 
vestigators using the General Clinical Research Center at the 



University of Texas Southwestern .Medical School in Dallas 
tested the effect of dietary supplementation with alpha-toco- 
pherol on the time course of oxidation of LDL in a random- 
ized placebo-controlled single blind Study. Two groups of 12 
male subjects were given either placebo or alpha-tocopherol 
(SOD iu/day) for a period of 12 weeks. Alpha-tocopherol ther- 
apy did not result in any side effects or exert any adverse effect 
on the plasma lipid and lipoprotein profile. While the lipid 
standardized alpha-tocopherol levels were similar at baseline, 
the supplemented group had 3.3-fold and 4.4-fold higher levels 
compared to placebo at 6 and 12 weeks. The Study showed that 
alpha-tocopherol supplementation results in an increase in 
plasma and LDL alpha-tocopherol levels resulting in a de- 
creased susceptibility of I ,DL to oxidation; these findings could 
have major implications in the prevention of atherosclerosis. 

Hormone Replacement To Prevent Osteoporosis. Prog- 
estins frequent!) are used in combination with estrogen for 
the prevention or treatment ol post menopausal osteoporosis. 
Progestins protect against the undesirable hyperplastic effects 
ol estrogen on the endometrium. The possibility that prog- 
estins might antagonize the beneficial effects of estrogen on 
calcium homeostasis has received little attention. Considering 
that possibility, researchers using the General Clinical Re- 
search ('enter at the University of California, San Francisco, 
examined whether the addition of progestin to estrogen would 
alter estrogen's capacity to raise serum levels of 1,25(01 I)2D, 
the potent hormone that stimulates gastrointestinal absorp- 
tion of dietary calcium. l,25(OH)2D is the active metabolite 
ot vitamin D. and is a major regulator of both intestinal cal- 
cium transport ami bone metabolism. 

Women wuhm 5 years of menopause were treated with 
three cycles of oral estrogen (E2) followed by three cycles of 
12 plus progestin. Such drug doses are those typically used for 
treating postmenopausal symptoms ami preventing post- 
menopausal osteoporosis. 12 increased both total and free 
l,25(OH)2D concentrations in a dose dependent fashion, sug- 
gesting that part of the capacity of E2 to prevent osteoporosis 
could be attributed to this effect of 1,25(0] 1)21). These levels 
increased progressively over the three cycles of treatment with 
estrogen alone. With the addition of progestin, the levels of 
total and free 1,25(01 1)21) returned toward baseline, indicat- 
ing that the progestin was interfering with the effect of E2 on 
calciotropic hormone. The results support the hypothesis that 
progestin antagonizes part of the salubrious effects of estrogen 
on bone mineral homeostasis and indicate the need for further 
srudy of what is optimal hormone replacement to prevent os- 
teoporosis in post menopausal women. 

Studies in Hypertension. A wide range of blood pressure-re- 
lated investigations have been conducted by investigators 
using the Outpatient General Clinical Research Center at 
Johns Hopkins University. Areas of special interest have in- 
cluded etiologic factors in essential and secondary hyperten- 
sion, the role of ethnicity in development of hypertension and 
its complications, the value of ambulatory blood pressure 
monitoring and cardiovascular reactivity testing as indepen- 
dent predictors of cardiovascular risk, and the value of non- 
pharmacologic interventions in the treatment and prevention 
of hypertension. With respect to the latter, these investigators 
are currently providing national leadership for two major tri- 
als of non-pharmacologic therapy (the Trials of Hypertension 



Agency Innovations 



Prevention [TOHP]; the Dietary Interventions in the Elderly 
Trial [DIET]) and for an NHLBI-sponsored initiative to de- 
velop a national policy for primary prevention of hyperten- 
sion. Findings from the first phase of TOHP indicate that 
weight loss and sodium restriction are the most effective inter- 
ventions for lowering blood pressure in persons with a high- 
normal blood pressure. New information has been provided 
regarding the efficacy of stress management and supplementa- 
tion with either potassium, calcium, magnesium, and fish oil, 
as well as factors related to achievement and maintenance of 
weight loss and sodium restriction. Phase II of TOHP is com- 
paring the value of weight loss and sodium restriction (alone 
and in combination) to prevent the occurrence of hyperten- 
sion during long-term (>3 years) follow-up. 

Protective Effects of a Live Attenuated SrV Vaccine with 
a Deletion in the NEF Gene. Vaccine protection against 
HrV, the causative agent of human AIDS, and the related 
simian immunodeficiency virus (SIV) in nonhuman primate 
models has proved to be extremely difficult. Investigators at 
the New England Regional Primate Research Center have 
found that a constructed deletion in the auxiliary gene nef 
causes SIV to replicate poorly in rhesus monkeys and to ap- 
pear nonpathogenic in this normally highlv susceptible host. 
Rhesus monkeys vaccinated with live SIV (with the nef gene 
deleted) were completely protected against challenge by in- 
travenous inoculations of live, pathogenic SIV. These find- 
ings suggest that the deletion of nef or of multiple genetic el- 
ements from HIV may provide the means for creating a safe, 
effective, live attenuated vaccine to protect humans against 
AIDS. 

Advanced Technology for Diagnosis and Treatment of 
Multiple Sclerosis. Investigators at the University of Wash- 
ington Regional Primate Research Center have explored the 
use of magnetic resonance imaging (MRI) of the brain to diag- 
nose and directly monitor the effects of treatment for multiple 
sclerosis. Using a nonhuman primate model of multiple scle- 
rosis known as experimental allergic encephalomyelitis (EAE), 
they and other researchers have demonstrated that MRI, 
which provides an x-ray-like image ot the interior of the brain, 
gives a useful, objective means of monitoring the course of the 
disease. Using brain tissue from animals induced to develop 
EAE, it is possible to determine what changes in the brain give 
rise to the changes observed on MRI. Thev have found that 
the MRI changes most likely reflect a breakdown of the blood 
barrier and the influx of inflammatory cells and fluid into the 
area of damage. 

This work has suggested, however, that even MRI does not 
pick up the earliest changes in the brain. One important 
change is the degradation of myelin, a substance that surrounds 
and provides electrical insulation to the individual nerve fibers. 
Two other applications of magnetic resonance technology are 
currendy being explored to determine whether it is possible to 
detect this early aspect of the disease process. Preliminary re- 
sults indicate that these techniques, known as magnetic reso- 
nance spectroscopy (which provides chemical information 
about brain tissue) and diffusion imaging, are very promising. 

Co-Grafting of Dopamine Producing Cells and Nerve 
Tissue Enhances Treatment of Parkinson's Disease. 

Studies were conducted at the Yerkes Regional Primate Re- 



search Center to determine the effectiveness of transplanta- 
tion of dopamine-producing cells into the central nervous 
system in the treatment of neurological deficits. Compar- 
isons were made between the effects ol transplantation of 
fetal brain cells versus adrenal medullary cells, as well as the 
effectiveness of various surgical techniques. The nonhuman 
primate model uses the administration of MPTP to selec- 
tively destroy dopaminergic cells in the nigro-striatal path- 
way; this results in a movement disorder which is quite simi- 
lar to parkinsonism. Initial studies demonstrated the 
potential for correcting the Parkinson-like movement abnor- 
malities using either adrenal medullary tissue or fetal mesen- 
cephalic tissue in the macaque model. A new co-grafting 
technique which uses adrenal medullary and peripheral 
nerve tissue together was found to greatly enhance survival 
of the transplanted cells, apparently due to the production of 
neurotrophic growth factors by the peripheral nerve cells. As 
a result of these findings in the monkey model, Emory Uni- 
versity physicians were the first in the United States to use 
co-grafting of dopamine-producing cells (adrenal tissue) and 
nerve tissue in the surgical treatment of a patient with 
Parkinson's disease. 

Cytokine Use in the Treatment of Neoplastic Diseases 
and in Bone Marrow Transplant Protocols. Studies have 
been conducted at the Yerkes Regional Primate Research 
Center to determine the effects of recombinant human 
hematopoietic growth factors (rhHGF's) on the 
hematopoietic system of nonhuman primates. During and 
after rhHGF administration, blood and bone marrow are 
serially sampled and assayed for various components of the 
hematopoietic system, including marrow and peripheral 
blood colony forming cells, marrow and blood CD34* cells 
(primitive immune and myeloid cells), marrow megakary- 
ocyte number and ploidy, and marrow nucleated red cell 
number. The rhHGFs evaluated, either singly or in various 
combinations, include recombinant interleukin-3 (IL-3), 
interleukin-6 (IL-6) and granulocyte-macrophage colony 
stimulating factor (GM-CSF). IL-6 resulted in increased 
megakaryocyte size, ploidy and number, and in a marked 
increase in CD34* cells in the peripheral blood. These ini- 
tial studies were performed in animals with unperturbed, 
steady state hematopoiesis. To stimulate the marrow re- 
generation that follows chemotherapy, studies have been 
initiated to determine the appropriate chemotherapy regi- 
men to produce thrombocytopenia and neutropenia of suf- 
ficient magnitude to determine the effects of treatment 
with recombinant hematopoietic growth factors. As a result 
of positive findings in these studies, physicians in the De- 
partment of Medicine and the Bone Marrow Transplanta- 
tion Program at Emory University will soon initiate studies 
to use recombinant IL-6 in the treatment of women with 
breast cancer. This will be the first clinical trial of recombi- 
nant IL-6 to aid recovery of the bone marrow in breast can- 
cer patients who have been given high-dose chemotherapy 
and subsequent marrow stem cell transplants. Studies in the 
nonhuman primate model indicate that the use of bone 
marrow transplantation, in combination with cytokines, 
will allow the use of higher doses of chemotherapy in a 
safer and more effective manner. This treatment may also 
be applicable to women with breast cancer in earlier stages 
of the disease. 



o 



Prevention '93/94: Federal Programs and Progress 



© 



National Eye Institute (nei) 

The National Eye Institute (NET) w;^ created on August 
16, 1968, by Public Law 90-489, with the mission to improve 
prevention, diagnosis, and treatment oi blinding and disabling 
eye disorders. NEI conducts and supports basic and clinical 
research, research training, health information dissemination, 
and other programs relative to blinding eye diseases, visual 
disorders, mechanisms of normal \isu.il function, preservation 
ol sight, and the special health problems ol the blind. 

NEI Prevention Highlights 

Diabetic Retinopathy. Diabetic retinopathy accounts for 
approximately 1- percent ol new cases ol blindness each year 
in the United States. Diabetes increases the risk of blindness 
25-fold over that of the general population, and it is estimated 
that 8,000 Americans become blind each year as a result ol di- 
abetic eye disease. The Diabetic Retinopathy Vitrectomy 
Study demonstrated that the maintenance or recovery ol vi- 
sion could he improved when eves with very severe prolifera- 
tive diabetic retinopathy and/or hemorrhage underwent 
prompt vitrectomy. Important new findings from the Early 
Treatment Diabetic Retinopathy Study (ETDRS) demon- 
strated that careful follow-up and deferral ol laser photocoag- 
ulation surgery until retinopathy progressed to a high-risk 
stage were highly effective in preventing severe visual loss in 
non-proliterative or early proliferative disease. Data from the 
1 I DRS indicate that currently recommended treatments are 
90-percent effective in preventing blindness in patients with 
proliferative retinopathy. 1 he E I DRS also showed that local 
photocoagulation reduced the 3-year rate of moderate visual 
loss in eves with diabetic macular edema from 53 percent lor 
untreated eyes to 13 percent lor treated eves. 

Through the National Eye Health Education Program 
(NEHEP), public .md professional education activities stress 
the importance of earh detection and timely treatment of dia- 
betic eve disease. Three \TI studies will evaluate the ellicacv 
of an inexpensive educational intervention to promote annual 
ophthalmic screening for low income African American 
women, develop a culture-specific and conimunilv -based edu- 
cation program for the prevention of eve disease in diabetic 
Native Americans, and evaluate programs that are designed to 
increase the use ol ophthalmologic sen ices among people w nh 
diabetes. 

-Macular Degeneration. The Age- Related Eye Diseases 
Study i \RI T)V is to evaluate the effect of high-dose antioxi- 
dant vitamins and zinc on the progression of age-related mac- 
ular degeneration (AMD). Patients will be randomized to ei- 
ther a high-dose dietary supplement or a low-dose dietary 
supplement and followed for a minimum ol 7 years to assess 
the progression of AMD and the formation of cataracts. 

Glaucoma. Researchers in the Fluorouracil Filtering Surgery 
Study (FFSS), sponsored bv NEI, examined the efficacy of 
tive-fluorouracil (5-FU) in slowing the growth of undesirable 
scar tissue that may reverse the beneficial effects of surgery for 
glaucoma. Results from the FFSS showed that patients receiv- 
ing 5-FU were less likely to require further surgerv and 
needed fewer or no daily medications. 



Herpetic Eye Diseases Study. The Herpetic Eye Diseases 
Study (HEDS) is a randomized, controlled clinical trial de- 
signed, in part, to evaluate whether oral acyclovir, given to pa- 
tients in combination with steroid and antiviral eve drops, mi- 
proves the management of active herpes simplex stromal 
keratitis. HEDS investigators recently reported that oral acy- 
clovir is no Tetter than placebo in treating herpes simplex 
stromal keratitis. \ second randomized clinical trial conducted 
as part of HEDS examined the effect ol steroid eve drops m 
combination with topical trifluridine as a treatment for active 
herpetic stromal keratitis. Preliminary findings, from HEDS, 
indicate that corneal inflammation was held in check longer 
and cleared taster in patients treated with steroids. 

The Collaborative Corneal Transplantation Studies. 

Corneal transplantation is performed on approximately 
00 eves annually in the United States. The importance of 
matching histocompatibility and tissue-specific antigens in 
those at high risk for graft rejection has been assessed in the 
Collaborative Corneal Transplantation Studies (CCTS). Re- 
cently, CCTS reported that donor/recipient tissue typing had 
no significant long-term effect on die success of corneal trans- 
plantation. Instead, the CCTS found that high-risk transplant 
survival could be improved through the use ol two inexpensive 
strategies: donor/recipient ABO blood type matching and post 

operative high-dose topical steroid therapy. 

Retinitis Pigmentosa. Rhodopsin is the light -sensitive pro- 
tein that initiates the conversion ol light energv into v isual sig- 
nals in the retina, a process called phoiotransduction. An im- 
portant recent advance in vision science has been the 
identification of the rhodopsin gene and its localization to 
chromosome 3. With this information, NTI-supported scien- 
tists examined the rhodopsin gene in individuals with autoso- 
mal dominant retinitis pigmentosa ( \DRP). a blinding, inher- 
ited retinal degenerative disease that also has been mapped to 
chromosome 3. They discovered a point mutation (nucleic 
acid substitution) in the rhodopsin gene in patients with one 
form ol ADRP. This discovery provides a locus for studies of 
the mechanisms that lead to blindness in ADRP. 

Myopia and Other Refractive Errors. In the United States, 
about 2s percent of the adult population is myopic (near- 
sighted) and requires some form of optical correction to see 
clearly beyond arms' length. Recently, research on the mecha- 
nisms of myopia development has begun to move rapidly due to 
the availability of animal models. NEI grantees have identified 
periods fit development m which newborn animals are suscepti- 
ble to visual deprivation-induced myopia and demonstrated that 
recovery from deprivation myopia is possible during the devel- 
opment period. Other NFI-supporred scientists have provided 
evidence that myopia development is influenced by local retinal 
neurotransmitters. In recent animal experiments, dopamine has 
been suggested as a factor that links ocular growth control to vi- 
sion, and dopamine agonist have been shown to partially pro- 
tect the eye from myopic elongation. 

Uveitis. Uveitis, inflammation within the eye, can be caused by 
infectious agents and other external factors or it can be an au- 
toimmune disease. Previously, researchers had determined that 
a retinal protein, S-antigen, injected into the eye of lower 
mammals induces an experimental autoimmune uveitis (EAU) 



Agency Innovations 



that mirrors the human disease. NEI-intramural scientists 
studying the EAU have identified four uveitogenic peptides 
within the S-antigen molecule. One of these S-antigen pep- 
tides has structural similarity to bacterial and viral antigens diat 
induce uveitis. These studies confirm that an immune response 
against an immunogenic sequence shared by host and foreign 
antigens can elicit autoimmune inflammation. These findings 
also support the hypothesis that infectious agents exhibiting 
"molecular mimicry" (shared immunogenic sequences) may 
play a pivotal role in the etiology of autoimmune disease. 



National Heart, Lung, and Blood 
Institute (nhlbi) 

The National Heart, Lung, and Blood Institute (NHLBI) 
provides leadership tor a national program in diseases of the 
heart, blood vessels, lungs, and blood, and in the uses of blood 
and management of blood resources. Through research in its 
own laboratories and through extramural grants and contracts, 
the Institute conducts an integrated program that includes 
basic and clinical investigations, clinical trials, epidemiologic 
studies, and demonstration and education projects. These ef- 
forts have contributed significantly to the realization of the 
NHLBI's ultimate goal — the prevention of disease. 

NHLBI Prevention Highlights 

Prevention and Control of High Blood Pressure. The Na- 
tional High Blood Pressure Education Program (NHBPEP) 
was initiated in 1972 as a cooperative effort between the 
NHLBI and major professional and voluntary health agencies 
to reduce death and disability associated with high blood pres- 
sure. NHBPEP efforts are targeted to professional, patient, 
and public audiences, and focus on stimulating disease preven- 
tion and control activities, developing and disseminating edu- 
cational materials, and providing technical support to commu- 
nity health programs. The NHBPEP regularly reviews and 
revises its educational materials and messages to verify that 
they reflect the current scientific consensus. The Fifth Report 
of the Joint National Committee on Detection, Evaluation, 
and Treatment of High Blood Pressure recommends a new 
scheme for classifying high blood pressures. It emphasizes that 
even mildly elevated blood pressure, formerly called mild hy- 
pertension and now called Stage I hypertension, is associated 
with a higher risk for mortality and morbidity and requires 
treatment. The Working Group Report on the Primary Pre- 
vention of High Blood Pressure recommends lifestyle 
changes — weight control, reduced consumption of salt and al- 
cohol, and increased exercise. The recommendations are sup- 
ported by data that show population-wide blood pressure re- 
ductions of as little as 2 mm of mercury decrease mortality 
from both heart disease and stroke. 

The NHLBI is planning to implement a number of new 
prevention initiatives concerned with hypertension. One of 
them will contribute to our understanding of the role of di- 
etary patterns on blood pressure regulation by testing the ef- 
fect of patterns that (1) reduce total fat, saturated fat, and cho- 
lesterol and increase modestly polyunsaturated fat and 
protein, (2) increase potassium, calcium, magnesium, and 
fiber, and (3) incorporate both approaches. 



Because the blood pressure of many patients cannot be ade- 
quately controlled by non-pharmacologic means alone, addi- 
tional research is needed to identify optimal drug treatment 
approaches. Although existing data show that blood pressure 
control can generally be obtained by any of the five major 
classes of antihypertensive agents, namely, diuretics, beta- 
blockers, alpha-blockers, calcium channel blockers, and an- 
giotensin converting enzyme inhibitors, only the first two 
classes, the diuretics and the beta-blockers, have been shown 
to reduce mortality and morbidity. Since diuretics are widely 
available as generic drugs, treatment with them is generally 
significantly cheaper than treatment with drugs from either 
die calcium channel blocker class or the angiotensin convert- 
ing enzyme class. NHLBI will initiate a new practice-based 
clinical trial of antihypertensive pharmacologic treatment to 
determine whether the combined incidence of fatal coronary 
heart disease and non-fatal myocardial infarction differs be- 
tween individuals who receive diuretic-based therapy and 
those who receive alternative antihypertensive agents. 

Treatment of Patients with Hemoglobin Disorders. In- 
vestigators have attempted to treat patients with hemoglobin 
disorders such as sickle cell disease and Cooky's anemia by re- 
versing the "hemoglobin switch" that occurs naturally at birth 
so that normal fetal hemoglobin can be produced. Although 
the chemical, hydroxyurea, increases fetal hemoglobin in 
some patients with sickle cell disease, concern remains about 
its therapeutic use because it suppresses bone marrow and its 
long-term toxicity and effects on growth and development are 
unknown. However, recent work reported by scientists from 
the NHLBI and NIDDK reduced the treatment levels of hy- 
droxyurea and achieved similar results as earlier studies by also 
administering growth factor erythropoietin. A recent pilot 
study of butyrate, a naturally occurring nontoxic chemical 
used as a flavor additive in some foods, demonstrating its abil- 
ity to "switch on" production of fetal hemoglobin when in- 
jected into the blood stream. An oral form of butyrate, 
phenylbutyrate, has been developed and is expected to be 
longer-acting and more convenient for patient use. Successful 
extension of these studies may lead ultimately to the first 
treatments for sickle cell disease and Cooley's anemia that are 
both effective and free of serious side effects. 

Prevention of Obesity in Minorities. Obesity is a significant 
risk factor for cardiovascular disease which is particularly 
prevalent among minorities. The NHLBI Growth and Health 
Study is an observational study to investigate development of 
obesity in a cohort of black and white girls who were aged 9- 
10 years at initial evaluation. Results to date indicate that, as 
early as age 9, black girls begin to manifest risk factors that 
will make them 2 to 4 times mote likely to develop heart dis- 
ease as adults than white girls. Black girls are significantly 
heavier than white girls, and consume more calories, with a 
larger percentage of calories from fat. They also have greater 
skinfold measurements — an indicator of body fat — and, by age 
9, significandv higher blood pressures than white girls of com- 
parable age. On the other hand, black girls have lower blood 
levels of triglycerides, a fat linked to higher risk of heart dis- 
ease, and higher levels of high density lipoprotein (HDL, the 
so-called "good" cholesterol that offers protection against 
heart disease). However, these advantages begin to disappear 
at puberty, which black girls experience earlier than their 







Prevention '93/94: Federal Programs and Progress 



© 



white counterparts. The investigators speculate that black 
yirls may have an initial genetically determined advantage 
with regard to risk of heart disease that diminishes with in- 
creasing obesity . 

The Strong Heart Study is a major X 1 1 1.151 research effon 
that is providing important new information on risk factors 
for cardiovascular disease in 45- to 74-year-old American In- 
dians. Two of the major risk factors for cardiovascular dis- 
ease, obesity and diabetes, occur with a high frequency 
among study participants. Diabetes is 10 to 20 times more 
common in American Indians than in whites. Obesit) is also a 
risk factor for diabetes that is present in 28-50 percent ot the 
population. Geographical differences e\ist in the risk for obe- 
sity, with the highest rates occurring in Arizona and the low - 
est occurring in the Dakotas. Because a marked increase in 

obesity occurs between the ages of HI and 25, N11LBI initi- 
ated a stud\ to determine whether development of obesity 
can be slowed or prevented in American Indian and Alaska 
Native school children. Results of the study will be available 
at the end of the decade. 

Smoking ( lessation in Minorities. \ 1 II Bl is currently con- 
ducting extensive smoking research targeting minority popu- 
lations. Results from the epidemiological study on Coronary 
Artery Risk Development in Young Adults (CARDIA), an 
\l II.HI-inui.ued research program, demonstrate significant 
differences m smoking behavior among minority and white 
adults. Despite decreases in the percentage ot smokers in the 
I nited St.ites over the last 25 years, smoking patterns remain 
unchanged among minorities. In addition, .i greater percent- 
age of Black Americans are current smokers than whites, and. 
according to some previous studies, blacks tend to smoke ciga- 
rettes with a higher tar and menthol content. Recognizing that 
smoking contributes to the higher incidence ot chronic dis- 
eases and premature death among minorities. \lll Bl initi- 
ated a smoking cessation research program to develop inter- 
ventions that are both culturally sensitive and specifically 
designed to reach minority populations. Preliminary data indi- 
cate that such targeted interventions are effective in decreas- 
ing smoking rates among minorities. 

Prevention of Stroke in Sickle (ell Disease Patients. 
Among sickle cell patients, thrombotic stroke is the most com- 
mon form ot cerebrovascular event during the first two 
decades ot lite, while hemorrhagic stroke occurs more tre- 
quendy thereafter. Overall, prevalence estimates tor cerebral 
infarction and intracranial hemorrhage range from 6 to 34 
percent. Definitive diagnosis often required intra-arterial an- 
giography, an invasive procedure that entails some risk. 1 low- 
ever, the noninvasive techniques now available tor imaging 
large cerebral vessels require neither contrast materials nor ra- 
dioactive blood tracers and have very few associated risks. 
Thus, sickle cell disease patients at risk for serious ischemic 
events can now be safely identified and treated before such 
problems occur. 

National High Blood Pressure Education Program — 
Strike Out Stroke. NHLBI, through the NHBPEP, initiated 
a Strike Out Stroke campaign. Financial and technical support 
was provided to 12 State health departments in the so-called 
Stroke Belt of the southeastern United States, to help them 



develop public education and other approaches to reduce the 
prevalence ot high blood pressure and smoking among blacks. 
Included in the Strike ( >ui Stroke effort were church and 
community-based programs, media campaigns selectively tar- 
geted tor particular audiences, development and dissemination 
ot easy-to-read materials tor persons with low literacy skills, 
and d.it.i collection and evaluation projects. The effort was so 
successful that Nl 1LB1 plans to broaden the scope ot activities 
in the currently participating State health departments to in- 
crease the participation ot high-risk individuals. 

Prevention of Thrombosis. I hrombosis, the formation ol 

clots in blood vessels, is the precipitating event for most heart 
attacks and stroke. One approach to the development of an- 
tithrombotic drugs is to design specific and selective inhibitors 
of thrombin, the central enzyme responsible for platelet ag- 
gregation and clot formation. A significant Step was recently 
taken towards that goal with the identification of the structure 
ol a molecule on human platelets th.it binds thrombin. II this 
molecule can be blocked so that binding ot thrombin is inhib- 
ited, then clot formation will be retarded. Two types of mole- 
cules have been synthesized, namely antibodies to the binding 
domain, and molecules mimicking the binding domain. Initial 
studies usiiili these agents appear promising and suggest that 
thej may lead to the development ol more effective an- 
tithrombotic drugs to use in the prevention ol heart attacks 
and stn ike. 

Prevention of Stroke and Cardiovascular Disease in the 
Elderly. The Systolic Hypertension in the Elderly Program 
(SI ll'l'i is a double-blind, randomized clinical trial sponsored 
by Nl II. Bl and the National Institute on Aging. Isolated Sys 
tolic hypertension (IS! I), a condition in which systolic blood 
pressure is elevated but diastolic pressure is normal, affects 
about ' million Americans age 60 and older. It is associated 
with a 2 to 3 times higher risk of stroke, ami also an increased 
risk ot coronary heart disease, heart failure, heart attack, and 
sudden death. However, it was previously unclear whether 
lowering systolic blood pressure reduced these risks. SHEP 
assessed the effects of treatment ol ISI I with commonly used, 
inexpensive antihypertensive drugs. The study found that the 
treated group experienced average 5-year reductions ol 36 
percent for stroke. 27 percent lor coronary heart disease, and 
32 percent for all cardiovascular events. These results form 
the basis lor important new medical care recommendations 
that are expected to have a substantial beneficial impact on 
morbidity and mortality among older Americans. 

Correction of Mucus Abnormality in Cystic Fibrosis. Al- 
though progress in palliative treatment of cystic fibrosis (CF) 
has increased median survival from 4 years of age in 1960 to 
28 years in 1990, the search for a cure has been impeded by an 
inadequate understanding of the underlying genetic defect. 
The situation changed dramatically with the discovery of the 
CF gene in 1989. Study of the gene and its product has en- 
abled scientists to recognize that CF is caused by abnormal 
transport of chloride and sodium ions in the lung cells, result- 
ing in development of thick, sticky mucus. Recently, NHLBI- 
supported researchers identified two naturally occurring nu- 
cleotides, adenosine triphosphate and uridine triphosphate, 
that appear to correct the chloride secretion problem in air- 
way cells. Their findings, taken together with earlier observa- 



Agency Innovations 



tions that aerosol administration of die diuretic amiloride de- 
creases sodium absorption in the upper airways of CF patients, 
suggest that a combined therapy to prevent abnormal mucus 
production may lead to improved survival and reduced mor- 
bidity among CF patients. 

NHLBI-supported researchers are also continuing to inves- 
tigate methods for correcting the underlying genetic defect in 
cystic fibrosis so that the disease itself can be prevented. Clini- 
cal studies of gene therapy for cystic fibrosis have already 
begun in the intramural laboratories of the NHLBI. In addi- 
tion, the Institute will implement an initiative to stimulate fur- 
ther research on gene therapy approaches for cystic fibrosis 
and other heart, lung, and blood diseases. 

Prevention of Heart Failure Mortality. Heart failure affects 
approximately 2 million Americans. It is characterized by dys- 
function of the left ventricle that is manifested in a low ejec- 
tion fraction, and by associated edema, shortness of breath, 
and variations in blood pressure. Persons with left ventricular 
dysfunction who are asymptomatic for heart failure are at high 
risk for developing heart failure and persons with heart failure 
experience high rates of hospitalization and mortality. In an 
important NHLBI-sponsored program, Studies of Left Ven- 
tricular Dysfunction, two concurrent randomized, double- 
blind controlled trials were conducted on patients with low 
ejection fraction to evaluate the effects of administering an an- 
giotensin-converting-enzyme inhibitor (enalapril). Individuals 
who were symptomatic for heart failure were enrolled in the 
treatment trial, while asymptomatic individuals and individu- 
als who were only mildly symptomatic were enrolled in the 
prevention trial. In the treatment trial, enalapril was shown to 
reduce mortality and hospitalizations and to improve func- 
tional capacity of the heart. In the prevention trial, enalapril 
therapy was shown to achieve significant reductions in the oc- 
currence of new onset heart failure and in hospitalizations. 

Prevention of Passive Smoking. In a recent study supported 
by NHLBI, a health education program to encourage non- 
smoking among new mothers led to a reduction, by half, in the 
prevalence of persistent lower respiratory symptoms in their 
babies. This study indicates that educational programs to in- 
form expectant mothers on infant health care could include a 
passive smoking reduction component and thereby prevent 
respirator)' infections and symptoms. 

Prevention of Coronary Restenosis. In many patients with 
coronary heart disease, balloon dilatation of obstructed coro- 
nary arteries, known as percutaneous transluminal coronary 
angioplasty (PTCA), can improve blood flow to the heart and 
thereby relieve symptoms. The major limitation of this 
widely used procedure is that restenosis (reocclusion) occurs 
in approximately 30 percent of patients, many of whom sub- 
sequently undergo a repeat PTCA procedure or coronary by- 
pass surgery. Restenosis is due mainly to the accumulation of 
smooth muscle cells in the vessel wall. Recently NHLBI-sup- 
ported investigators prevented restenosis in rats and rabbits 
by using an innovative genetic therapy approach that selec- 
tively blocks the activity of specific genes required for smooth 
muscle cells to divide. Initial results indicate that this poten- 
tial therapeutic strategy is inexpensive and highly effective at 
very low doses and with short treatment times. A major ad- 
vantage is that treatment is localized to a small portion of the 



blood vessel and therefore avoids the problems of side effects 
and lack of specificity inherent in systemic approaches. Al- 
though further work in non-human primates is necessary be- 
fore extending this research to humans, the results offer the 
prospect of improved long-term outcomes following PTCA 
therapy. If proven successful in humans, the approach could 
reduce dramatically the risk, inconvenience, and cost of re- 
peat PTCA. 

Lowering Blood Cholesterol in Children. An expert panel 
convened by the National Cholesterol Education Program has 
recommended that a two-pronged approach be implemented 
to lower the cholesterol and saturated fat intakes of children 
and adolescents. First, a public health approach is proposed 
that would have adolescents and children above the age of 2 
years follow a diet low in cholesterol and saturated fat. Sec- 
ond, for children and adolescents from high-risk families, as 
determined by family history, an individualized patient-based 
approach would be used, in which targeted screening and in- 
tervention is applied, with diet as the primary treatment. The 
recommendations were published as a supplement to the jour- 
nal Pediatrics. Booklets outlining the recommendations have 
also been prepared for parents and for different age groups of 
children. 

In addition, NHLBI is supporting a study, entitled the Di- 
etary Intervention Study in Children, to determine the long- 
term safety, efficacy, acceptability, and feasibility of a modified 
fat diet in children with elevated serum LDL (low density 
lipoprotein, the so-called "bad" cholesterol). Preliminary data 
show significant reductions in blood LDL levels and no ad- 
verse effects on growth. In fact, children in the intervention 
group were taller and leaner than the controls. The study will 
be extended for an additional 7 years so that the long-term ef- 
fects of dietary intervention on the growth and development 
of children can be determined. 

The NHLBI plans to survey physicians who provide pri- 
mary care to children in the United States to obtain informa- 
tion on their current attitudes, knowledge, and practice pat- 
terns related to pediatric preventive cardiology. The 
information provided by the survey will allow the Institute to 
target more effectively future educational efforts related to 
improved cardiovascular health for children. 

Smoking Among Youth. Evidence exists of long-term effec- 
tiveness of school-based smoking prevention programs. In an 
intervention community, students were exposed to behav- 
iorally oriented health education from 6th through 10th 
grades, with a major emphasis on smoking avoidance in the 
7th grade curriculum. Annual surveys revealed that both 
smoking prevalence and smoking intensity (that is, number of 
cigarettes smoked per week) diverged progressively between 
students in the intervention and control communities begin- 
ning in the 7th grade. The differences were maintained 
through the 12th grade. By the end of high school, only 14.6 
percent of students in the intervention community were 
smokers, compared with 24.1 percent in the control commu- 
nity. These results suggest that school-based intervention 
within a supportive community context can substantially re- 
duce smoking initiation in adolescence. 

Neonatal Respiratory Distress Syndrome. Current re- 
search is focused on the timing and dosage of surfactant ther- 



Prevention '93/'94: Federal Programs and Progress 



apy, and with understanding why sonic infants with respira- 
tory distress syndrome (RDS) do not improve despite admin- 
istration of surfactant. Attention is also being directed toward 
the role of maternal antenatal steroid therapy in enhancing 
lung maturation and surfactant function. Although antenatal 
steroids can significant]) lower RDS mortality when adminis- 
tered to expectant mothers at risk for delivering premature in- 
fants, they are only used in a small percentage of cases. An up- 
coming Consensus Development Conference, jointly 
sponsored by the N11LB1 and other components of the Nil 1. 
will attempt to develop clearly defined indicators for antenatal 
steroid therapy that will encourage more routine use of this 
preventive strategy in appropriate patients. 

Prevention of Transfusion-Associated Hepatitis. An 
Nl [LBI-sponSOred study recently assessed the risk of transfu- 
sion-associated hepatitis C v irus (HCV) in a cohort of patients 
undergoing cardiac surgery. Introduction of anti-HCV 
screening of blood was associated with an 85-percent decline 
in risk of HCV infection among recipients of blood or blood 
products: infection rates dropped from 45 to 3 per 10,000 
units transfused. The effectiveness of donor screening is ex- 
pected to improve even further with the recent introduction ot 
a second-generation 1 ICY ass.n ; it is estimated that this newer 
assav will reduce the risk ol I ICY post-transfusion hepatitis to 

approximately 1.5 cases per 10,000 units transfused. 

Physical Activin lor Cardiovascular Health. \ recent 
NHLBI-supported studv reported unproved lipid profiles 
when an exercise regimen was added to a diet reduced in total 
fat, saturated tat. and cholesterol, \lter 1 year ot follow-up in 
this randomized, controlled clinical trial, interventions con- 
sisting of diet plus exercise offered significant advantages over 
diet alone, in both men and women. Some gender differences 
were noted. For example, men assigned to the diet plus exer- 
cise group lost significant!} more weight and significantly 
more fat than men in die diet onl) group, whereas no compa- 
rable differences were found in either measure among women. 

Women's Health Study. The role of aspirin in the primary 
prevention ot cardiovascular disease in women is being investi- 
gated. Observational data from the NHLBI-supported Nurses 
Health Studv indicate that women who reported taking an av- 
erage ot one to six aspirins per week had a 25-percent reduc- 
tion in risk of myocardial infarction, hut no change in stroke or 
cardiovascular mortality. Although these data are suggestive, 
results from a more detailed, controlled studv- are needed to 
determine whether prophylactic aspirin use in women can pre- 
vent heart disease. It is for this purpose that the Nl ILBI is sup- 
porting the Women's Health Study, a randomized, double- 
hlind. placebo-controlled trial of low-dose aspirin for 
prevention ot heart disease and of beta carotene and vitamin E 
for prevention ot both cancer and heart disease in women. Re- 
cruitment ot the over 40,000 nurses expected to participate in 
the study began in 1992. The results will permit informed de- 
cisions to be made on whether to recommend prophylactic as- 
pirin and vitamin use by women to prevent heart disease. 

Silent Ischemia. NHLBI has undertaken the Asymptomatic 
Cardiac Ischemia Pilot study to assess the feasibility of con- 
ducting a full scale clinical trial that would determine the rela- 
tive effectiveness and safety of usual care, stepped medical 



therapy, or mechanical revascularization (angioplasty or coro- 
nary artery bypass grafting) in preventing morbidity and mor- 
tality among patients who sutler from asymptomatic ischemia. 
Another study, Psychophysiological Investigations ot Myocar- 
dial Ischemia, is investigating neurological and psychophysio- 
logical factors that affect the manifestations and presentation 
of myocardial ischemia. Since individuals who experience is- 
chemia are at increased risk for premature mortality, en- 
hanced understanding ot the underlying mechanisms and an 
improved ahilitv to identif} the presence ol ischemia arc ex- 
pected to lead to prevention ot morbiditv and mortality. 

Asthma. A growing awareness of the critical role played by in- 
flammation in the pathogenesis of asthma has stimulated .i 
search hit new drugs to prevent crises in this chronic disease. 
Leukotrienes, chemical substances formed from the metabo- 
lism ot arachidonic acid by the enzyme 5-lipoxgenase have re- 
cently been implicated in the airway obstruction of asthma. 
This discovery by NHLBI-supported investigators has led to 
development and testing of candidate drugs designed to block 
either 5-lipoxygenase or the leukotriene receptor. Preliminary 
results have been highly promising; a significant improvement 
in lung function was observed in patients with mild-lo-moder- 
ate asthma who received blockers ot 5 lipoxygenase. These 
agents may prove to he the first new drugs in the last 25 years 
for treatment of asthma. 

A number ol Nill I'd sponsored activities are under wav to 
encourage physicians to use state-of-the-art techniques to diag- 
nose, treat, and manage asthma. Although asthma generally can 
he controlled with expert medical treatment and sell-manage- 
ment, many patients tail to receive adequate care or to follow 
prescribed treatment plans. The Institute is taking specific ac- 
tion to promote improved control of this chronic disease. There 
has been widespread dissemination ol the "Guidelines lor the 
Diagnosis and Management of Asthma," and the new "Report 
of the Working Group on Asthma ami Pregnancy" is currently 
being distributed. Further, the Institute recently initiated a new 
in. the \sthm.i \c.ulemic Award. This award will support 
ams in medical schools to stimulate the development, im- 
plementation, and evaluation of high-quality curricula related 
to asthma. Such programs are expected to increase the opportu- 
nities for students, house staff, and others to learn the principles 
and practice ol preventing, managing, and controlling asthma, 
anil to promote the development of a faculty capable of provid- 
ing appropriate instruction in asthma. The NHLBI will initiate 
a program to develop innovative outreach programs for ensur- 
ing appropriate management and control of asthma. In addi- 
tion, the Institute will establish a network of interactive asthma 
clinical and health education research units to permit rapid as- 
sessment of innovative treatment methods and to ensure that 
health professionals are aware of the most current knowledge 
on asthma diagnosis and management. 

Tuberculosis. There are now in the United States an excess of 
25,000 tuberculosis (TB) cases over what had been predicted 
based on trends from the early 1980. The disease is spreading 
quickly, especially among minority population groups and in 
HI\ '-infected patients. Also at high risk of TB infection are per- 
sons living or working in group or institutional settings, such as 
hospitals and correctional facilities. Among the problems associ- 
ated with control of TB are inadequate resources, clinical manage- 
ment errors, and patient non-adherence to treatment regimens. 



© 



Agency Innovations 



The NHLBI recently initiated a Tuberculosis Academic Award to 
encourage the development of high-quality medical school curric- 
ula related to TB control; to enhance awareness by health care 
providers ot ethnic, cultural, socioeconomic, and medical dimen- 
sions of TB; and to foster collaboration with community organiza- 
tions to control TB in localities with high incidence of disease. 
Minority institutions and urban institutions in areas widi a high 
incidence ot TB are particularly targeted by this new effort. 

The Institute is initiating two new research programs fo- 
cused upon TB and the lung. The first, Expression of Tuber- 
culosis in the Lung, is intended to identify the manner in 
which factors such as gender, ethnicity, heredity, and associ- 
ated disease states (e.g., HIV infection, silicosis) influence sus- 
ceptibility to and severity ot TB in die lung. Cellular and mol- 
ecular mechanisms that define the immunologic and 
pathophysiologic responses to the TB bacterium will also be 
explored. A second program, Non-Immune Defense Against 
Tuberculosis in the Lung, seeks to determine the manner in 
which non-immune mechanisms may play a role in defending 
the lung against TB infection, particularly in the early stages 
of disease. The results of these research programs are expected 
to lead to new directions or prevention and control of TB in- 
fection and its associated morbidity and mortality. 



National Institute on Aging (nia) 

The National Institute on Aging (NIA) supports biomedical 
behavioral and social research on processes of aging and the 
disease problems and other special needs of older people. 
Within this broad mandate, one of the goals of the NIA is to 
develop an overall strategy related to health promotion and 
disease prevention. 



NIA Prevention Highlights 

Frailty and Injuries. NLA began the Frailty and Injuries: Co- 
operative Studies of Intervention Techniques (FICSIT) pro- 
gram in 1990. FICSIT is a set of clinical trials of interventions 
against frailty and injuries, and has demonstrated the feasibil- 
ity of conducting interventions in frail older individuals. 
Moreover, it has found certain exercise regimens to be effica- 
cious in improving strength, balance, and endurance in older 
persons, and some interventions have shown a 30-percent re- 
duction in fall rates. These trials were completed in 1993. In- 
terventions tested in the different FICSIT trials have been 
combined to plan a comprehensive program to prevent injuri- 
ous falls and decline in independent functioning in individuals 
75 years and older. This program will begin in 1994 or 1995. 

New Hormone Therapies for Preventing Frailty. New 

studies to evaluate the effects and safety of growth hormone 
and other trophic factors are designed to test whether the 
aging process can be reversed or slowed. Nine controlled clin- 
ical trials have begun to determine whether strength, mobility, 
balance, and endurance can be improved when people are 
given trophic factors. If this, and other research, establish the 
efficacy of trophic agents, such hormone replacement therapy 
could become an important tool for preventing physical frailty 
among older men and women. 

This program was stimulated by recent reports that growth 
hormone administration to healthy men 65 and older with low 



growth hormone levels increased lean body mass and de- 
creased body fat and the effects of aging on the skin. In some 
people, hormone levels decrease with age. The critical ques- 
tion is whether chronic administration to restore or maintain 
these hormones will keep people strong and fit. These sub- 
stances may have promise for halting or reversing degenera- 
tive changes in bone, muscle, nerves, and cartilage, which lead 
to frailty. 

NIA intramural scientists are conducting collaborative stud- 
ies in which women and men over 65 years of age, who have 
relatively low levels of insulin like growth factor I and low lev- 
els of sex steroid hormones are treated for 6 months with ei- 
ther growth hormone injections, sex-appropriate transdermal 
steroid patches, sex steroid plus growth hormone, or placebos 
for both hormones. Because sex hormones and growth hor- 
mones act on bone, the question of whether both types of hor- 
mone together may act synergistically and have an advantage 
over either alone is being explored. 

Osteoporosis. In 1991, NIA began the STOP/IT program 
(Sites Testing Osteoporosis Prevention/Intervention Treat- 
ment), a set of clinical trials to test promising means of main- 
taining or increasing bone strength in persons age 65 and 
older. These trials will generate information on the efficacy of 
treatments such as estrogen, calcium, vitamin D, and physical 
exercise in older individuals. Enrollment of participants in this 
study was proceeding in 1993. A full scale hip fracture preven- 
tion trial, based on the results of STOP/IT, should be feasible 
by the mid-1990s. 

A study using the co-twin model proved to be the first to 
demonstrate in children a direct, significant relationship be- 
tween the amount of calcium consumed and bone density. Al- 
though average dietary calcium intake in 22 preadolescent 
twin pairs closely approximated the RDA, the twin who re- 
ceived extra calcium (of about 700 milligrams per day), 
showed greater gains in bone mass, particularly in the forearm 
and spine. Because peak bone mass, or the bone mass achieved 
at maturity, is a major determinant of bone mass in later life, it 
is anticipated that increases in bone mass during the growth 
spurt are likely to offer increased protection against osteo- 
porosis and related fractures in old age. 

Urinary Incontinence. In 1991, NIA-sponsored researchers 
showed that a 6-week program of bladder training was an ef- 
fective way to prevent incontinence for many women. These 
results were incorporated into Clinical Practice Guidelines by 
the Agency for Health Care Policy and Research, and have 
been distributed to health care providers. Researchers have 
subsequently demonstrated that weight reduction is also use- 
ful in obese women with urinary incontinence. Ongoing stud- 
ies are examining both medication use and behavioral means 
to prevent incontinence. 

The Baltimore Longitudinal Study of Aging. The Balti- 
more Longitudinal Study of Aging (BLSA), NIA's major in- 
tramural study of human aging, continues to produce findings 
relevant to disease prevention. The study panel of 1,150 men 
and women from 20 to 97 years in age come to Baltimore 
every 2 years for a 2V2-day visit to be intensively studied for 
physiologic and behavioral changes. There are over 50 BLSA 
research projects in progress and emphasis is being given to 
research relevant to women and minorities. 



Prevention ' 9 3 / ' 9 4 : Federal Programs and Progress 



I ongitudinal Studies of Prostate Disease. Little is currently 
known about the relationship between prostate growth, dis- 
ind symptomatology. Previous findings from the Balti- 
more Longitudinal Study ol Aging suggest th.it rates of change 
in prostate-specific antigen (PSA) m.n be a sensitive and accu 
rate method of detecting prostate cancer, and perhaps BP1I. 
These studies suggest chat longitudinal measurements of PSA 
in persons with prostate cancer show striking increases, some 4 
to 6 years prior to clinical diagnosis. \ collaborative P>l ,SA lon- 
gitudinal study is underway to distinguish normal growth from 
prostate disease; to identity hormonal changes related to the 
development and progression of prostate disease; to refine the 
use of repeated PSA measurements to detect the earl) stages ol 
prostate disease; to identity factors associated with obstructive 
symptomatology; and to study possible differences in these re- 
lationships between African Americans and Caucasians. It is e.\ 
pected chat understanding these relationships will be useful in 
designing prevention, screening, and intervention programs to 
reduce the mortality, morbidity, -\nd health care costs related 
to prostatic disease. 

\ variety ofbiologic.il samples is collected from BLSA par- 
ticipants at sequential visits and banked. As potential early 
markers for disease are identified, this bank together with the 
extensive health and behavioral data assembled over tune on 
the participants allows an instantaneous longitudinal study to 
be conducted relating the early marker to risk factors and 
health outcomes. 

Diagnosis of Diabetes VIellitUS. It has long been suspected 
tlvat diagnostic standards for interpreting the oral glucose tol- 
erance test may need to be age-specific; that is. that different 
outpoints may be required for young, middle-aged, and older 
adults. The last revision of recommendations lor interpreting 
plasma glucose values was made in P'" 1 '. At that tune, there 
were insufficient data to justify' the setting of age-specific stan- 
dards. Data from the BLSA collected over the past 50 years 
now provides evidence bearing on this question. Fasting 
plasma glucose had been defined as "normal" up to a level of 
1 1 5 mg/dl, as "borderline" between 1 1 5 and 1 39 mg/dl. and as 
"diabetic" above 140 mg/dl. The BLSA data show that fasting 
plasma glucose is a "graded" variable comparable to cholc 

| or blood pressure (cerebrovascular disease). 
Levels ot glucose much lower than 115 at all ages have now 
been shown to carry increased risk tor the future development 
ot oven diabetes. Furthermore, the standards lor diagnosing 
"impaired glucose tolerance" (2-hour plasma glucose levels ol 
140 to 199 mg/dl) need to be adjusted for age. Up to age 60. 
however, these standards seem to be appropriate; after age 60, 
no subject developed diabetes after many years of follow-up if 
the 2-hour glucose level was below 1 57 mg/dl. Thus, the range 
of 140 to 15" in older individuals should probablv not earn' the 
diagnosis of "impaired glucose tolerance." These results point 
to the necessity of more long-term follow-up studies ot the de- 
velopment of diabetes and its complications. 

Hearing Loss and Aging. Understanding the rate and causes 
of age-associated hearing loss looking at preventable factors 
such as noise, ototoxic medications, vascular changes, or other 
lifestyle factors. Findings from the BLSA show that the longi- 
tudinal rates of decline in hearing sensitivity are approximatelv 
twice as great in men as women, even among men and women 
employed in relatively noise-free occupations. To date, this is 



the largest and longest longitudinal stiuK ol hearing thresholds 
conducted in the world. Although many factors can cause hear- 
ing loss, the consensus among audiologists is that noise expo 
sure at the workplace, in military service, or in leisure activities 
such as hunting, woodworking, ami loud music may play a role 
in the more rapid hearing loss in men. Longitudinal estimates 
of age-associated loss ot hearing sensitivity will be useful tor es- 
timating future prevalence of hearing impairment and for iden- 
tifying factors that mav be preventable. 

Mechanisms of Race and Gender Differences in Arterial 
Pressure with Aging. It is hypothesized that age-related 
changes in large artery stiffness may be an important determi- 
nant of deleterious thickening of heart muscle and of subse- 
quent cardiovascular events. The NLA intramural program has 
embarked on a major new initiative to quantity the age-associ- 
ated increase in arterial stiffness in relation to race and gender 
and to characterize its effects on the heart ami brain. Initial re- 
sults indicate that older persons with higher fitness levels have 
arteries that are less stiff than those of less fit individuals. Lon- 
gitudinal follow-up should help determine the effect ol vascu- 
lar stillness on the dev clopment ot heart disease and stroke. 

Sell (are. \n \ 1 A-supportcd Study provides the first nation- 
ally representative sample data base on sell-care behaviors 
practiced by Americans 65 years and older who live in the 
community. Preliminary findings suggest that there is a con- 
siderable range of adaptation in a person's environment as 
the) age. B) acquiring equipment and learning special skills to 
adapt to specific functional limitations, older people find ways 
to maintain their independence tor as long as possible. For ex- 
ample. 13.6 percent of the population uses a cane. 11.1 per- 
cent have moved things to lower shelves to be within easy 
reach, and 2 v2 percent get help to prepare meals. Practice of 
health promotion and disease prevention behaviors is wide- 
spread in the population ol community-based older adults. 
Fifty-six percent report gelling adequate sleep, SS percent eat 
breakfast regularly, 77 percent avoid eating between meals, 58 
percent maintain appropriate bod) weight, 96 percent either 
never drink or have moderate alcohol consumption (no more 
than two drinks in a sitting), 55 percent never have smoked 
cigarettes, and 68 percent remain physically active with sports, 
walks, gardening, or other forms ol exercise. 

Risk Factors and the Health Experience of Older Per- 
sons. Using data collected as part of the Alameda County 
Study, a population-based epidemiologic study begun in 1965, 
investigators have conducted a series of analyses that demon- 
strate the strong relationship between a wide variety of behav- 
ioral, social, and demographic factors and risk of death from 
all causes (even in those 70- ( H years old who were followed for 
1" years). More recent analyses focusing on functional out- 
comes provide additional support for the continued impor- 
tance of social and behavioral risk factors throughout the life 
course. For example, smoking, income, and depression 
strongly predict limitations in mobility for individuals who de- 
velop chronic disease (e.g., heart trouble, stroke, arthritis). 
Being a current smoker (odds ratio=2.87; 95 percent CI 1.58- 
5.24). having an inadequate level of family income adjusted for 
family size (odds ratio=1.81, 95 percent CI 0.90-3.65), and 
being depressed (odds ratio=2.43, 95 percent CI 0.99-5.96) 
were all associated with substantially elevated risks of develop- 



. 



Agency Innovations 



ing mobility limitation in these persons with incident chronic 
conditions. Thus the impact of disease on functioning might 
be lessened if social or behavioral interventions are applied at 
different points in the course of an illness. 

Influenza Vaccination. Despite the demonstrated effective- 
ness of influenza vaccination, baseline adherence rates among 
at-risk elderly are around 10 percent, and lower still among 
low socioeconomic groups. Phone call reminders reliably in- 
crease adherence rates. However, they are limited because (1) 
a human operator must make a call and continue calling if 
there is no answer and (2) the human operator must speak a 
language comprehended by the target older adult. NIA-sup- 
ported researchers have now developed a voice-mail system in 
which patients' names are recorded only once, the message 
concerning the vaccination is recorded only once, and the 
message can be recorded in as many languages as are spoken in 
die calling area, and which can also make appointments for 
patients bv comparing available openings to the patients' 
schedules. In a field trial, the system increased adherence rates 
in a low socioeconomic group above baseline and above other 
reminder means (mailed and verbal announcements). Voice 
mail was most effective when used in combination with the 
other reminder means. 

Established Populations for Epidemiologic Studies of the 
Elderly. The Established Populations for Epidemiologic Stud- 
ies of the Elderly consists of prospective epidemiologic studies 
of approximately 14,000 persons 65 years of age and older in 
four different communities: East Boston, Massachusetts; two 
rural counties in Iowa; New Haven, Connecticut; and seg- 
ments of five counties in north-central North Carolina. The 
North Carolina sample included 54-percent black participants. 
Recent findings indicate that even after age 65, smoking cessa- 
tion has health benefits; annual smoking cessation rates of 10 
percent were observed; and smokers tended to quit more often 
after the diagnosis of heart attack, stroke, or cancer. 

Women's Health and Aging Study. The Women's Health 
and Aging Study is a longitudinal study that is evaluating a 
population of non-institutionalized women age 65 and older 
who have moderate to severe physical disability. Field work 
for this study began in November 1992. The cohort includes a 
representative sample of older women and of black women 
from Baltimore, Maryland. The baseline assessments are ex- 
pected to be completed over an 18-month period with the fol- 
low-up data collection and analyses to continue through Feb- 
ruary 1998. The overall goal is to understand the causes and 
course of physical disability 7 in older women living in the com- 
munity. The study will focus on defining those diseases and 
conditions responsible for disability, as well as gaining an un- 
derstanding of the progression of disability and how it is influ- 
enced by underlying disease. 



National Institute on Alcohol 
Abuse and Alcoholism (niaaa) 

Alcohol abuse and alcohol dependence are serious problems 
affecting approximately 15 million adult Americans and sev- 
eral million adolescents and children. Annually, at least 



1 00,000 deaths in the United States can be attributed to alco- 
hol-related causes. NIAAA is the lead Federal agency for re- 
search on the causes, consequences, treatment, and prevention 
of alcohol-related problems. All research supported by 
NIAAA potentially is relevant to prevention, but the Institute 
recognizes a special need to encourage research that specifi- 
cally addresses prevention. 

NIAAA Prevention Highlights 

Prevention Research Center (PRC). The Prevention Re- 
search Center in Berkeley, California, is the NIAAA national 
research center dedicated to die prevention of alcohol prob- 
lems. PRC undertakes both basic and applied research to 
identify risk factors for alcohol abuse as well as preventive in- 
terventions. The PRC utilizes a public health systems model 
as a means to understand the social and physical environments 
that influence alcohol use and abuse. PRC research focuses on 
family drinking patterns and influences in blue collar as well as 
Mexican American families; the role of family, peers, and the 
mass media in adolescent drinking initiation and patterns; 
drinking associated with the workplace; environmental and 
systems factors that increase community alcohol problems; 
and the contribution of drinking to violence. PRC has under- 
taken a series of studies examining effects of existing regula- 
tions and law enforcement on alcohol availability. 

PRC] is currently engaged in a long-term community preven- 
tion trial of strategies to reduce alcohol-involved injuries and 
deaths in two communities in California and one in South Car- 
olina, with matched control community for each experimental 
site. The comprehensive set of interventions includes server 
training, increased law enforcement, public education, reduced 
access to alcohol by underage persons, and changes in local zon- 
ing for alcohol oudets. These interventions will be tracked for 3 
years, followed by a year of evaluation and institutionalization 
of these programs in each experimental community. 

Prevention Research Branch (PRB). The Prevention Re- 
search Branch within NIAAA stimulates, monitors, reviews, 
and evaluates extramural research on the prevention of alco- 
hol-related problems, and provides technical assistance to po- 
tential applicants. The grant portfolio includes studies of pre- 
intervention research issues (e.g., risk and protective factors, 
decision-making processes, and measuring instruments) as 
well as studies that test the effectiveness of single or multiple 
prevention strategies. 

Youth and Young Adults. NIAAA-supported projects are 
studying the developmental sequence of alcohol use within 
adolescent populations, risk and protective factors, alcohol ex- 
pectancies and beliefs, and norm setting and norm enforce- 
ment by parents, schools, peer groups, health care providers, 
and the community. Family influences have been identified as 
key factors in adolescent drinking, and interventions that target 
the family are being tested. School-based social skills-training 
interventions have been effective in preventing alcohol use 
among high-risk youth; and school programs that include fam- 
ily and community components are being evaluated. 

Minority Issues. In 1993 the Prevention Research Branch is- 
sued a new program announcement for research on the pre- 
vention of alcohol-related problems among ethnic minorities. 



Prevention 93/'94: Federal Programs and Progress 



Currently, NIAAA and CSAP are supporting studies that 
focus on protective and risk factors for alcohol abuse among 
African American adolescents; alcohol abuse and anti-social 
personality disorders among Navajos; and the development of 
culturally appropriate preventive interventions for Mexican- 
Americans. 

\1 VAA continues to fund an examination ol the effects <>l 
cultural change on the drinking practices of Mexican Ameri- 
cans. Results indicate that Mexican American women may be 
important implementors of prevention strategies, since they 
may pl.n special roles in helping to reduce alcohol problems 
among family and friends. A major finding from a study on 
culture predictors of drinking behaviors among blacks and 
whites is that race alone is not directly associated with alcohol- 
related problems. However, race indirectly affects drinking 
behaviors through us association with socioeconomic status 
and attitudes toward drinking. 

Alcohol and AIDS. Researchers are studying both correlative 
and causal relationships between alcohol use and unsafe sexual 
practices related to 1 11V transmission. Current studies include 
pre-intervention and intervention research on diverse gay and 
heterosexual populations. The involvement of alcohol in risky 
behavior is being studied through ethnographic interviews 
with adolescents, diary ami daily log methods, and population 
surveys. Interventions are being tested through random as- 
signment ot individuals to theory-based conditions. Preven- 
tion strategies include counseling, interactive school-based 
programs, ami community-oriented interventions. Nl\\\ 
supported research has found that teens who report heavy al- 
cohol use take greater sexual risks; that increased alcohol con- 
sumption increases the likelihood of unprotected intercourse 
with new partners; ami that sexual and drinking behaviors dif- 
fer among racial and ethnic groups. 

Mcobol and Women. Results of an ongoing investigation ol 
the efficacy ot specially designed alcohol abuse prevention 
strategies lor professional and business women indicate that 
providing small amounts ot information over a long period ot 
time is an effective intervention for this target group. Among 
these women, social context is an important predictor ot 
women's drinking behavior. Another project is developing and 
evaluating a multicomponent preventive intervention to in- 
crease abstinence during pregnane) among economically dis- 
advantaged women. A third study is examining factors that in- 
fluence beliefs about alcohol use during pregnancy, and how 
these beliefs and other moderation variables influence drink- 
ing behaviors ot pregnant women. Women's issues are also 
addressed in studies concerned with violence and warning la- 
bels. At a workshop in the fall of 1993, a research agenda for 
the prevention of alcohol-related problems among women was 
developed. 

Cornmunity/Environmental Issues. NIAAA and the Center 
for Substance Abuse Prevention at SAMHSA are jointly spon- 
soring two community-based prevention trials that test the ef- 
fectiveness of community-based, multifaceted, integrated pro- 
grams for preventing alcohol-related problems. One study is a 
random-assignment trial of interventions aimed at reducing 
youth access to alcoholic beverages. The other is an efficacy 
trial of interventions to reduce alcohol-related trauma in two 
matched pairs of communities. Both studies focus on changing 



the practices ot major community institutions and implement- 
ing multifaceted, coordinated packages of intervention efforts. 
Additional community studies funded solely by NIAAA include 
an efficacy trial to reduce trauma, an adolescent-focused pic 
vention program, and a trial to reduce drinking and driving. 

Aging. NIAAA encourages research to develop methodolo- 
gies appropriate lor research on older adults, to elucidate pat- 
terns ot alcohol use and abuse, to identify risk and protective 
factors, and to develop relevant primary and secondary inter- 
ventions. Two research issues of special concern are late onset 
alcohol abuse and moderate drinking that places the individual 
at risk for alcohol-related problems due to health conditions, 
medication interactions, decreased alcohol tolerance, or activ- 
ities requiring motor skills, lwo Nl \\\-tunded studies are 
analyzing existing longitudinal data and collecting prospective 
data to describe temporal patterns of alcohol and medication 
use. identify predictors of abuse, and assess the moderating 
roles of living accommodations and other social factors. Both 
studies will be valuable aids in designing interventions. 

Primary Care. Priman care settings are being used to iden- 
tify individuals and groups who may benefit from alcohol pre- 
vention strategies. 1 he effectiveness of brief interventions in 
these settings is under investigation, such as motivational 
counseling and didactic, media-based, and self-instructional 
interventions. Outcome measures include changes in current 
drinking patterns, modification ol alcohol-related intentions 
or health beliefs, and increases in perceived self-efficacy and 

sell control. 

Worksite Issues. Several new studies locus on causal factors 
and prevention approaches to alcohol problems at the work 
site. This research examines links between job characteristics, 
work environment, and alcohol-related problems. Researchers 
study mediating factors, such as stress and alienation, and 
moderating factors, such as the alcohol culture of the work 
setting, the presence of employee assistance programs (EAPs), 
social support, and marital discord. 

At corporate, worksite, and workgroup levels, researchers 
explore how social control systems form, sustain, and enforce 
work-related drinking norms and practices. They also exam- 
ine how organizational policies and informal controls may be 
used to discourage drinking. Other studies assess how much 
attitudes of key worksite personnel influence EAPs, the com- 
parative effectiveness of locating intervention programs within 
or outside work settings, and the influence of the social envi- 
ronment and social support on the effectiveness of workplace 
interventions. 

Economic Issues. The price and availability of beverage alco- 
hol have been studied as predictors of per capita alcohol con- 
sumption, traffic crashes, and cirrhosis mortality rates. Studies 
have also considered econometric models of addictive behav- 
ior, the effects of alcohol consumption on labor force out- 
comes, optimal taxation, and the effects of advertising. 

Intentional and Unintentional Injuries. A significant pro- 
portion of violent events and traumatic injuries are associated 
with alcohol use. Through a new program announcement is- 
sued in 1993, NIAAA is encouraging research on biological 
and psychosocial mechanisms underlying linkages between al- 



Agency Innovations 



cohol consumption and interpersonal violence. Two ongoing- 
studies are examining the reciprocal effects of alcohol abuse 
and family violence. One study focuses on the contribution of 
childhood violence and violence by husbands to the develop- 
ment of alcohol problems in women. The other tests the hy- 
pothesis that childhood victimization is a significant risk factor 
for the development of alcohol problems in both males and fe- 
males. Research on unintentional injury includes studies of in- 
terventions designed to reduce drinking and driving, and a na- 
tional survey examining the contribution of alcohol to 
drownings and the impact of drinking-boating laws. 

Warning Labels. Survey-based warning label studies have ex- 
amined changes in label awareness, knowledge of hazards de- 
scribed, perceptions of risk levels, and alcohol-related behav- 
ior. Researchers have focused on various populations, 
including the general population of adults, black women seek- 
ing prenatal care, urban Hispanics, and youth. Laboratory 
studies concentrating on label design factors have investigated 
such features as message location and visibility. 

Future Directions. Investigators are completing a generic 
model of systematic research phases for alcohol prevention 
studies, including basic and applied research components. The 
model is relevant to investigator-initiated interventions and to 
"natural experiments," which are generally policy driven. Spe- 
cial foci for future research initiatives include the prevention 
of alcohol-related violence, the prevention of alcohol-related 
problems among women, and the effects of advertising and 
media strategies on drinking behavior. 

The PRB has completed for publication seven edited mono- 
graphs concerning research methods, economic issues, high- 
risk youth, prevention strategies lor adolescents, violence, 
marketing and media effects, and ethnic minorities. 



National Institute of Allergy and 
Infectious Diseases (niaid) 

The National Institute of Allergy and Infectious Diseases 
(NIAID) conducts and supports research contributing to a 
better understanding of the causes of allergic, immunologic, 
and infectious diseases and the processes involved in the trans- 
mission and development of the diseases. The ultimate goal is 
the development of better means for prevention, diagnosis, 
and treatment. In much of its prevention research, NIAID 
regularly collaborates with other Federal agencies, interna- 
tional and research organizations, and industry. 

NIAID Prevention Highlights 

Children's Vaccine Initiative. The Children's Vaccine Ini- 
tiative (CVT) is an international effort to develop new and 
improved children's vaccines that are safer, more effective, 
cheaper, and easier to administer. The ultimate goal of the 
CVI is to develop a single, heat stable, oral vaccine that will 
provide lifelong immunity to the major infectious diseases of 
childhood. NIAID's research on new and improved vaccines 
that will protect against specific priority diseases is poten- 
tially applicable for use in universal childhood immunization 
programs. 



The need for improved immunization against rubella has 
been demonstrated by recent outbreaks of rubella and measles 
in the United States as well as a report by the Institute of 
Medicine (IOM) on the adverse effects of the existing rubella 
vaccine. The report cited evidence that receipt of the RA 27/3 
rubella vaccine is causally associated with acute arthritis, as 
well as limited evidence that it is associated with chronic 
arthritis. NIAID-supported researchers made significant 
progress toward an improved vaccine by developing a DNA 
clone of the rubella virus. This advance will provide the tools 
to develop a new engineered recombinant vaccine that will not 
cause arthritis. 

Immunization programs using the two forms of polio vac- 
cines currently licensed in the United States may soon lead to 
eradication of paralytic polio. However, concerns about rever- 
sion to neurovirulence and vaccine delivery problems, such as 
the need for continuous refrigeration, have prompted NIAID 
research efforts to attempt to improve and create safer polio 
vaccines. NIAID-supported investigators replicated polio 
viruses in a cell-free, test tube system. This advance will allow 
scientists to study the biochemical and genetic properties of 
the virus and represents the first demonstration of in vitro syn- 
thesis ot a sell-replicating virus. Another research team devel- 
oped a transgenic mouse model that is susceptible to the 
human poliovirus and can develop paralytic disease. This 
model is being used to understand the pathogenesis of the 
polio vaccine's neurovirulence, which is an important step in 
the potential development of a safer vaccine. 

NIAID is supporting a major initiative to develop a vaccine 
to protect newborn infants against group B streptococcal 
(GBS) infections, the most common cause of sickness and 
death related to neonatal infection in this country. Immuniza- 
tion of infants is impractical for the prevention of GBS disease 
because most infections occur shortly after birth. However, 
immunization of women to stimulate maternal antibodies to 
protect the newborn is an alternative approach. NIAID is sup- 
porting the development of GBS glycoconjugate vaccines for 
immunizing pregnant women. A type III conjugated to 
tetanus toxoid vaccine is currently being evaluated in phase I 
clinical trials. 

Development of an HTV Vaccine. Before candidate HIV 
vaccines can be tested in humans, a large number of questions 
must be answered in animal models. One barrier to this effort 
is that HIV will cause disease only in humans. Therefore, re- 
searchers have examined in animals other virus-induced im- 
munodeficiency diseases. One of the more useful animal mod- 
els involves macaque monkeys infected with simian 
immunodeficiency virus (SIV), which duplicates many aspects 
of HIV in humans. Studies with the macaque monkey model 
showed that animals that had been successfully vaccinated 
against one strain of SIV using a whole, inactivated SIV vac- 
cine also were protected against a second strain of the virus. In 
continuing studies with an inactivated SIV vaccine, re- 
searchers found that immunized macaques were protected 
from SIV 8 months after receiving a final booster dose. This 
finding suggests that long-lasting immunity can be induced by 
a vaccine without the continuous maintenance of peak im- 
mune response. Another study showed that a live recombinant 
vaccine administered with a subunit protein boost protected 
macaques from SIV, lending further support to a combination 
strategy for producing an HIV vaccine. 



(ffi 



Prevention '93/94: Federal Programs and Progress 



(flft 



XIAID-supported researchers are developing another ani- 
mal model chat will add an invaluable resource for testing- HIY 
vaccines. Studies are underway to determine whether mice 
with severe combined immune deficiency (SCID) reconsti- 
tuted with human lymphocytes from uninfected people who 
received an 1 11Y vaccine are protected from infection. This re- 
search also will help investigators determine the components ol 
immunity that protect an organism from HIY infection. 

An HIY vaccine must provide long-term protection as well 
as a broad immune response that involves both types of lym- 
phocytes: T cells (which use cellular mechanisms) and B cells 
(which produce antibodies). Consequently, another important 
area in IIIV vaccine research is the development of adjuvants, 
substances that can bolster these immune responses. NIAID- 
supported researchers are Studying potent and novel vaccine 
adjuvants, including several based on different formulations of 
liposomes, lipid membrane particles that can be used to carry 
antigens. Other possible vaccine adjuvants involve the use of 
CO-polymers to stimulate the production of abundant and 
long-lasting antibody responses by H cells, as well as formula- 
tions known as immune-stimulating complexes (ISCOMs), 
which seek to induce specific cytotoxic T-cell responses to 
I11Y envelope proteins. Another adjuvant formulation being 
evaluated for its potential to induce activity is an analog ol 
muramyl dipeptulc (derived from bacterial cell walls). When 
incorporated into an oil-in-water emulsion, this potential ad- 
juvant induced significant antibody and cell-mediated re- 
sponses to 1 1IV antigens in small animals. 

HIY Vaccine Trials. The NIAID's Vaccine Evaluation Units 
are evaluating eight different 1 I IV vaccines, some of which are 
composed of the envelope proteins gpl20 or gpl60 found on 
the outer coat of the virus. These Studies are evaluating the 
satciv of the vaccines, determining whether the vaccines in- 
duce strong immune responses, and comparing responses to 
different doses ol each vaccine. At this time, there are not suf- 
ficient data on any particular candidate vaccine to support an 
efficacy trial. However, several 1I1V vaccine approaches may 
produce such data within 1-2 years. Because of this possibility, 
NIAID is continuing to establish the necessary infrastructure 
Scacy trials both domestically and internationally. 

Tuberculosis. XI AID has formulated a comprehensive re- 
search agenda with support for basic research into die biology 
of TB, the development of new tools to diagnose TB, the de- 
velopment of new drugs or new ways to deliver standard 
drugs, clinical trials of anti-TB therapies, die development of 
new vaccines to prevent TB, training to increase the number 
of TB researchers, and new ways to educate health care work- 
ers and the public about TB prevention. 

Current diagnostic tests to identify infected patients and to 
determine which drugs can be used for treatment take several 
w : eeks before results are available. Two XTAID-supported in- 
vestigators have developed techniques for rapidly identifying 
TB and determining the drug susceptibility of TB isolates. 
The first assay is based on polymerase chain reaction (PCR) 
technology. PCR enables the amplification of very small 
amounts of DNA. The researcher identified a fragment of TB 
DN V known as IS61 10, that is unique to M. tuberculosis and 
then developed a PCR method to assay TB direcdy from clin- 
ical specimens, such as a sputum sample. The other assay uses 
luciferase, an enzyme that is part of the system that makes fire- 



flies glow. The investigator constructed a mycobacteriophage 
(a bacterial virus specific for the TB microorganism) that con- 
tains the gene to produce luciferase and can be used to insert 
the luciferase gene into the TB bacterium. In the assay, the 
phage and luciterin are added to TB organisms from a patient 
specimen and an anti-TB drug. Using the investigator's sys- 
tem, light production would normally be seen within 15 min- 
utes However, if the organism is grown in the presence of an 
effective antibiotic, it will be killed and there will be no light 
production. Not only is this a rapid and sensitive method for 
detecting resistant strains, but because of its potential for au- 
tomation, large numbers of samples could be processed in a 
short rime. This assay can also be used tor screening large 
numbers of potential anti-TB drugs. 

Clinical trials conducted through the Terry Beirns Com- 
munity Programs lor Clinical Research on AIDS are evaluat- 
ing the safety and efficacy ol drugs to prevent active TB in pa- 
tients co-infected with 11IV and M. tuberculosis; determining 
whether a two-Stage TB skin test is more reliable than a sin- 
gle-stage test in HIV-infected individuals; determining pat- 
terns of drug resistant TB among patients in AIDS clinical tri- 
als; ami measuring the frequency of new TB infections among 
health care workers and volunteers at AIDS clinical trial sites. 

Asthma, \sihma morbidity and mortality are known to be ,i 
function of many factors, such as the patient's physiology, en- 
vironmental exposure to allergens, and access to medical care, 
as well as the quality of that care. I lowever, it is not known to 
what degree these factors account for the significant differ- 
ences in morbidity and mortality and whether other, unique 
factors contribute to the high rates of morbidity and mortality 
among blacks and 1 lispanics living in the inner city. 

\l \ID emphasizes research to identify and implement in- 
terventions lor the treatment and prevention ol asthma. Insti- 
tute supported scientists are conducting a carefully controlled 
clinical trial to lest the value of allergic immunotherapy in the 
treatment of childhood asthma. Another study that may have 
implications lor the treatment of asthma is an examination of 
the relationship between the disease and exposure to certain 
allergens (allergy-causing substances). Although house-dust- 
mile allergens generally have been diought to play a role in the 
initiation of an asthma attack, NIAID-supported scientists re- 
cently found that early childhood exposure to these substances 
also contributes to die actual development of the disease. 

XI Ml) is also supporting research to uncover and under- 
stand the mechanisms that induce occupational or environ- 
mental asthma. Among these efforts is the provision of fund- 
ing to the Institute of Medicine for a 2-year study to examine 
die nature, scope, and causes of adverse effects on human 
health caused by indoor allergens. 

To address the increasingly serious problem of asthma in 
minority children living in urban areas, NIAID has funded 
eight groups from seven cities to conduct the National Coop- 
erative Inner City Asthma Study. The first phase of this study 
will identify factors, particularly behavioral factors, that are 
contributing to increases in morbidity and mortality from 
asthma among minority children in inner cities. In the second 
phase, the identified factors will form the basis of a multicen- 
ter clinical trial to develop and evaluate behavioral and social 
approaches to reducing these rising asthma rates. 

Another program sponsored by NIAID to reduce asthma 
morbidity and mortality among blacks and other minority 



Agency Innovations 



groups involves the Asthma Education Program for Hospital- 
ized Inner-City Children, which is funded under the Insti- 
tute's Centers for Interdisciplinary Research on Immunologic 
Diseases. The study tested a self-management education pro- 
gram designed to help hospitalized asthmatic children control 
acute episodes of their disease. The study found that the edu- 
cation program increased the children's knowledge of the 
early warning signs of acute asthma, their sense of personal 
control, and their use of self-management techniques for 
acute asthma episodes. The program also decreased the chil- 
dren's use of emergency hospital services. In addition, 
NIAID's Asthma and Allergic Disease Cooperative Research 
Centers, as well as its Immunologic Disease Cooperative Re- 
search Centers, are exploring ways to reduce the severity and 
incidence of asthma in minority populations through out- 
reach, demonstration, and education programs in inner cities. 

Transplantation. Successful transplantation requires that the 
organ being introduced is not recognized as foreign. This 
recognition is based on major histocompatibility complex 
(MHS) antigens proteins located on cell surfaces that identify 
what is uniquely sent to the immune system. NIAID supports 
research to characterize histocompatibility antigens and to de- 
termine the manner in which they condition responses to 
transplanted organs and tissue. Institute-supported re- 
searchers recently found that when transplant patients have a 
certain histocompatibility antigen (DRw52), they are particu- 
larly able to recognize any donor organ as being foreign and 
thus are more likely to mount a reaction against the trans- 
plant. DRw52 is the first immune response gene to be mapped 
in humans and has broad implications for the ability to induce 
tolerance in transplant recipients. 

NIAID-sponsored research is investigating the use of mon- 
oclonal antibodies directed against specific cells to prevent 
kidney graft rejection. In one study, scientists compared 
T10B9.1A-31, a monoclonal antibody developed to enhance 
tolerance of bone marrow transplants, with OKT3, the mono- 
clonal antibody currently used to treat acute kidney graft re- 
jection. They found that the new treatment was as effective as 
OKT3 in reversing acute graft rejections but had fewer and 
less severe side effects. Moreover, patients using T10B9.1A-31 
had a lower incidence of infection than those using OKT3. 
One explanation for the greater success of T10B9.1A-31 is 
that it has less ability to stimulate immune responses such as 
the production of cytokines, chemicals that are known to have 
a role in graft rejection. 

NIAID has initiated the first NIH multicenter cooperative 
clinical trial in kidney transplantation. The goal of this study is 
to translate some of the most recent developments in basic re- 
search into new immunosuppressive agents to prevent and 
control kidney transplant rejection. A network of eight centers 
throughout the United States will evaluate emerging potential 
treatments, which may incorporate the use of drugs, mono- 
clonal antibody techniques, or biological interventions. 

Bone marrow transplantation has the potential to cure a vari- 
ety of diseases, including leukemia, lymphoma, congenital im- 
mune deficiencies, and metabolic disorders. A major obstacle in 
bone marrow transplantation continues to be graft-versus-host 
disease (GVHD), which occurs in 40 to 80 percent of patients 
who have donors with identical matches for MHC antigens and 
almost totally prohibits the procedure in patients without com- 
patible donors. A clinical trial conducted by NTAID-supported 



researchers has shown that more selective depletions of T cells 
(key contributors to immune defenses) with anti-T12 can pre- 
vent GVHD in most patients with identically matched donors 
without increased risk of graft failure. These findings indicate 
that selective depletions of T cells can prevent GVHD in a ma- 
jority of patients and almost totally eliminate chronic GVHD 
following bone marrow transplant. Moreover, this in vitro treat- 
ment eliminates the need for additional immune suppressive 
therapy in most patients and appears to reduce the incidence of 
transplant-related toxicity and mortality. 

Sexually Transmitted Diseases. In 1992, approximately 10 
million people in the United States were diagnosed with a sexu- 
ally transmitted disease (STD); it is estimated that 3 million in- 
fections occurred in teenagers. In fact, individuals younger than 
25 years of age accounted for 63 percent of the cases. STD rates 
are highest among ethnic minorities of lower socioeconomic 
status. In all STDs, except HIV infection, complications and 
long-term sequelae disproportionately affect women and their 
infants. Furthermore, studies of the role of STDs in HIV trans- 
mission indicate that both ulcerative and non-ulcerative STDs 
increase risk of HIV transmission 3-5 fold, independent of the 
effect of sexual behavior. 

NIAID has a comprehensive and multidisciplinary research 
agenda that is aimed at prevention and control of STDs. The 
agendas for primary, secondary, and tertiary prevention are 
based on (1) blocking transmission; (2) decreasing the dura- 
tion of infection; and (3) ameliorating disease or interfering 
with disease progression. 

Vaccines are strategically important for preventing both 
viral diseases for which there are no curative treatments and 
bacterial diseases for which antibiotic resistances are common 
or for which symptoms are so indolent that the patient neither 
seeks nor receives effective therapy. In addition to a strong- 
basic research effort, including the Research on Molecular 
Immunology of STDs (ROMIS) Program Projects, NIAID is 
involved in Phase I testing of vaccines for genital herpes, 
chlamydia infection, and gonorrhea. 

The development of rapid, inexpensive, easy-to-use diag- 
nostic tests that are appropriate for resource-limited settings 
such as the inner cities of the United States are critical for the 
prevention and control of STDs. Such tests are particularly 
important for women because clinical algorithms based on 
recognition of symptoms are ineffective. NIAID is supporting 
research for a rapid test for bacterial vaginitis and for chlamy- 
dial infection, as well as a modification of the PAP smear 
screening test for human papillomavirus detection and typing. 

Topical microbicides are chemical barriers, designed for in- 
travaginal use, which will inactivate sexually transmitted viral, 
bacterial, and protozoan agents. Ideally, these compounds will 
have no inherent toxicity or spermicidal activity and may be 
used without partner knowledge or consent. The NIAID sup- 
ports basic research related to this area' as well as a growing 
portfolio of applied/basic research. 

NIAID supports an integrated behavioral research effort 
that targets decreasing behaviors that increase risk for STD 
acquisition, duration, and progression, and increasing health 
promotion behaviors. The research effort is intervention ori- 
ented and integrates a microbiological or disease outcome 
with a behavioral outcome. The growing portfolio targets 
high-risk populations, including adolescents, women, and 
those of lower socioeconomic strata. 



Prevention ' 9 3 / ' 9 4 : Federal Programs and Progress 



National Institute of Arthritis 
and Musculoskeletal and Skin 
Diseases (niams) 

NIAMS conducts and supports research on the numerous 
tonus of arthritis, diseases of the musculoskeletal system, and 
diseases of the skin .is well .is on the normal structure and 
function of joints, muscles, bone, and skin. The impact of dys- 
function in the areas of arthritis and musculoskeletal and skin 
diseases is profound. These disorders include sequelae of 
trauma, congenital detects, inborn errors ol metabolism, and 
inflammatory and degenerative tonus of arthritis. They span 
the entire life cycle and are the mam cause of disability among 
members oi the work force. 

NIAMS Prevention Highlights 

Osteoporosis, l-'or osteoporosis. pre\ enrii in begins before the 
onset ol disease, when calcium supplementation, exercise, and 
other behavior modifications can result in strengthening bone 
or diminishing hone loss. Epidemiologic prospective studies 
have found a variety of life-style related (actors that can 
progress to hone loss. These t.ictors include lack of exercise, 
poor nutrition, cigarette smoking, excessive alcohol use, im- 
mobility, and certain drug treatments, such as corticosteroid 
and high thyroxine therapies. Investigators have demonstrated 
that weight-bearing exercise has a positive influence on hone 
mass. Longitudinal studies have shown that exercise training 
in post-menopausal women may either retard the rate of bone 
loss or increase the hone mass in appendicular and axial hone. 
Cross-sectional studies have found a positive association be- 
tween activity and hone mass. 

Studying prevention of falls, investigators have character- 
ized both the endogenous and the exogenous risk factors for 
falls among the elderly. Endogenous factors include the use of 
medications, postural hypotension, slowed reaction times, re- 
duced muscular strength, and vision loss. Exogenous factors 
include stair design, poor lighting, and environmental hazards. 
Simple, reliable tests have been developed to characterize in- 
dividuals at risk tor tails. 

Researchers have shown that the etiology of hip fracture in 
individuals over "II years ol age is dominated by fall direction 
and impact site and is influenced to a lesser degree by 
trochanteric (lateral upper thigh) fat thickness and hone den- 
sity. Vertebral fractures are more closely correlated with 
spinal bone density. Although vertebral fractures are less fre- 
quently the consequence of trauma, current evidence sul 
that spinal loading in the elderly during common daily activi- 
ties such as lifting may he associated with spontaneous 
fracture. 

Vitamin D analogs can help prevent loss of bone density re- 
sulting in osteoporosis. Modest increases in bone density may 
also occur, helping to reduce the risk of fracture. Researchers 
have also found that vitamin D therapy may ameliorate 
steroid-induced osteopenia. 

Prospective controlled studies using bone densitometry 
have clearly shown that estrogen replacement therapy admin- 
istered at or near menopause prevents bone loss that results 
from estrogen deficiency. Preventing this bone loss may de- 
crease the number of osteoporosis-induced fractures. Re- 
searchers have developed methods to measure bone mass at 



sites of potential fractures. This progress has led to prospec- 
tive research demonstrating that low hone mass at menopause 
is predictive ot the occurrence of future fractures ami can be 
used to select individuals for preventive intervention. Re- 
search has also shown that correcting low calcium intake can 
play a definite although limited role in reducing hone loss. In 
addition, calcium supplementation in early lite may play a role 
in maximizing hone mass. 

Osteoarthritis. Results from the Framingham study popula- 
tion suggest that weight change in women occurring in middle 
or later years affects the risk for subsequent symptomatic knee 
osteoarthritis. This effect was strongest in women whose base- 
line body mass index was high. Therefore, habitually over- 
weight women can substantially ami significantly lower their 
risk lor symptomatic osteoarthritis by losing weight. The 
Framingham investigation found that weight loss, over a pe- 
riod of years, reduces by half the chance of developing os- 
teoarthritis of the knee in women. The data suggest that over- 
weight women should he counseled to lose weight. 

Sports-Related Joint Injuries. Investigations ot injuries io 

ligaments :md menisci have linked certain sports with in- 
creased risk ol injury io specific joints, leading to possible 
wavs to prevent or limit these injuries. Other investigations 
have established that there is an increased risk of arthritic 
change after ligament and meniscus injury, Studies have 
demonstrated the repair potential of ligaments, menisci, and 
other suit tissue .\nd have shown thai ligament repair and re- 
construction may prevent subsequent meniscal injury and 
arthritis. Additional studies ol the epidemiology of sport-re- 
lated injuries, such as assessing the influence of equipment and 
playing surface, have shown reduction in the incidence of 
ankle fracture. 

Muscle and Tendon Damage. Advances in exercise include 
the use of isometrics to maintain and increase muscle strength 
among the elderly and to ameliorate or prevent atrophy asso- 
ciated with corticosteroid therapy, zero gravity, and immobi- 
lization. Strength training in the elderly leads to increases in 
muscle thickness and the near doubling of lower extremity 
strength. 'This training could help prevent falls and reduce dis- 
ability among the population most at risk for hip fracture. 
Other studies indicate that patients who receive corticosteroid 
therapy and participate in prescribed exercise programs have 
better treatment outcomes, including less atrophy, than those 
who receive corticosteroid treatment and do not exercise. In 
addition, investigators have shown that isometric exercise pro- 
grams partially prevent external muscle atrophy among 
astronauts. 

Repetitive Motion Joint Injury. Model studies have shown 
that fatigue, weakness, and lack of warm-up may predispose 
muscle to injury, thus indicating that fitness, strength, and 
warm-up may help prevent injury. Atrophic changes in mus- 
cle after disuse or injury have been shown to depend on mus- 
cle electrical activity and the duration of immobilization. 
Muscle tension induced by stretching prevents some of the 
disuse changes, may lead to new muscle protein synthesis, 
and can prevent contracture. Numerous related studies of 
electrical muscle stimulation in orthopedic conditions are not 
conclusive. 



Agency Innovations 



Investigations of overuse or repetitive motion injury have 
revealed the involvement of a variety of pathological 
processes. Researchers have observed degenerative regions 
within tendons and have found causes of pain, including in- 
flammatory conditions involving tendon sheaths and bursae. 
Thev have also observed inflammatory and fibrotic responses 
to repetitive injury that may mechanically compress or alter 
blood supply to a nerve. 

Systemic Lupus Erythematosus. Systemic lupus erythe- 
matosus (SLE) is a chronic inflammatory disease of unknown 
cause with a variety of clinical manifestations. According to 
many studies, blacks with lupus appear to have onset at 
younger ages, and with more severe manifestation than whites 
with SLE. 

NIAMS continues to work with the Task Force on Lupus in 
High-Risk Population in developing educational strategies di- 
rected to patients, the public, and health professionals that 
may help improve the outcome of lupus in populations at in- 
creased risk for the disease. The task force has launched a 
campaign entitled "What Black Women Should Know About 
Lupus," which encourages young black women to see a doctor 
or other health worker if they have a continuation of key 
svmptoms. The task force plans to expand the campaign and is 
working with black health professional organizations to reach 
this audience. 

Prevention of Skin Diseases. Research has clearly linked ul- 
traviolet (UV) light exposure to skin cancer and has established 
specific guidelines for protection regarding wavelength, time 
of day, and sunscreens. Investigators have also linked familial 
atypical moles (previously termed dvsplastic nevi) with an in- 
creased risk of melanomas and have identified early aggressive 
steps to prevent the development of more serious conditions. 



National Institute of Child Health 
and Human Development (nichd) 

Many health problems that afflict adults originate before 
birth or in childhood. Thus, the early stages of life offer ex- 
ceptional opportunities to prevent both physical and psycho- 
logical disorders and disabilities that can affect people at any- 
time in their lives. The concept of prevention is the catalyst 
driving much of the National Institute of Child Health and 
Human Development's (NICHD) research program. Virtu- 
ally even- aspect of the Institute's research is designed to pre- 
vent or ameliorate disease or disability. Some of this is direct 
prevention such as developing a vaccine to prevent life-threat- 
ening disease; some is designed to facilitate the application of 
research findings to patient care, including various aspects of 
family planning. The research program of the NICHD is 
multidisciplinary and ranges from studying molecular biology 
to understanding the motivations driving human behavior to 
developing the means to restore or enhance function in indi- 
viduals with a physical disability. 

NICHD Prevention Highlights 

Minority Health Interventions. NICI ID is providing scien- 
tific, technical, and administrative management of grants de- 



signed to develop, implement and evaluate a cooperative pro- 
gram of community-based health and behavioral interventions 
to lower the high rates of morbidity and mortality among mi- 
nority youth. The overall goal of this program is to encourage 
healthy behaviors and to help reduce the number of violence- 
related injuries and deaths, the incidence of sexually transmit- 
ted diseases (STDs), and the number of unintended pregnan- 
cies in minority youth ages 10-24. All projects stress the 
importance of targeting interventions to the specific needs of a 
particular community. 

NICHD has translated into Spanish a brochure, Pregnancy 
Busies, to provide Hispanics with answers to many common 
pregnancy questions, such as those involving nutrition and 
weight gain, birth defects, fetal alcohol syndrome, smoking, 
and drug use. 

Reproductive Behaviors. NICHD supports ongoing re- 
search on the social, cultural, economic, and psychological 
factors associated with behaviors that place individuals, partic- 
ularly in high-risk populations, at risk for infection with HIV 
or other STDs. These studies highlight the decision-making 
processes that lead to high-risk versus protective behaviors 
and factors that facilitate behavioral change. Diverse research 
settings permit investigators to assess the influence of cultural, 
ethnic, and gender factors on behavior. 

The choices that women and men make regarding their 
sexual conduct affect both their physical and mental health 
and their life outcomes. Researchers have shown that the 
early initiation of sexual activity is associated with early preg- 
nancy and childbearing, poor contraceptive use, greater num- 
ber of sexual partners, greater risk of STDs, and cervical can- 
cer in women. To develop ways to prevent these negative 
outcomes, NICHD researchers are exploring factors that af- 
fect the timing of sexual activity, partner choice, the types of 
activity in which the couples engage, and their decision to use 
(or not use) protection against disease and/or unintended 
pregnancy. 

Researchers are also trying to develop education programs 
to encourage parent-teen communication about premarital 
sexual intercourse and birth control. These studies will inves- 
tigate the dynamics of such communication and identify vari- 
ables in low-income black families that predict teen sexual be- 
havior and inconsistent birth control use. Other NICHD 
studies will continue to examine motivational factors in birth 
planning to better understand what motivates women to have 
or prevent births, and to give researchers more sensitive meth- 
ods for measuring these motivations. Researchers have found 
that improved motivational factors are effective predictors of 
contraceptive vigilance in a sample of sexually active, inner- 
city, adolescent girls. 

Barrier and Oral Contraceptive Research. Since the ad- 
vent of oral contraceptives, NICHD-supported researchers 
have been developing additional progestational components 
that can be used in synthesizing new progestins for oral con- 
traceptives. Researchers have examined the estrogenic com- 
ponent of oral contraceptives and have recently developed 
active estradiol derivatives. These compounds are more ac- 
tive than compounds found in currently available products 
and can be administered orally, transdermally, and through 
injection. Because estrogens play a crucial role in contracep- 
tive regimens and in hormone replacement therapy (HRT), 



Prevention '93/'94: Federal Programs and Progress 



XICHD scientists continue to evaluate these new deriva- 
tives for safety and utility. NICHD also plans to evaluate 

the causes of dysfunctional uterine bleeding, a major prob- 
lem in contraception and HRT. and ways to alleviate this 
condition. 

NICHD-supported research has also evaluated the contra- 
ceptive potential of RL" 4S6. a steroid that blocks proges- 
terone action, finding that RL 486 prevents pregnancy in 
guinea pigs, if given daily throughout the reproductive cycle. 
A companion study in non-pregnant women shows that 
small daily doses of the compound prevent normal function 
and development of the endometrium, suggesting that RL" 
4S6 might also he used as an effective contraceptive in 
women. 

Another critical feature ofNICHD's prevention research is 
its support ot studies to improve harrier contraceptives, such 
as condoms, diaphragms, anil spermicides, to prevent the 
spread ol STDs. In terms ot harrier contraceptives tor men, 
NIC 111) has supported attempts to improve condoms In 
grafting fluorocarbons onto the existing latex condor 
process that is being introduced by a well-known condom 
manufacturer. Researchers are also developing a new genera- 
tion of condoms made from polyurethane, which in theory are 
stronger than latex and could he manufactured with thinner 
walls. Condom preference studies suggest that men prefer 

polyurethane condoms to the latex ones. 

The development ot new and improved harrier methods for 
women, over which they can maintain control, is particularlv 
important in helping women actively protect themselves 
against STDs, including HIV infection. Specific data are still 
lacking on the efficacy of spermicidal preparations in prevent- 
ing I11Y. NIC] 11) is sponsoring research to develop chemical 
agents that may inactivate spermatozoa and STD pathogens 
by mechanisms other than surfactance and products that may 
he protective of cpithclia and have long-acting properties. 
\ K 1 II ) is also actively supporting research on spermicide-re- 
leasing diaphragms. 

The NIC 111) has also helped to pioneer a new harrier 
method for women, the female condom. This is a loose-fitting 
polyurethane pouch with a free inner ring that collapses (like a 
diaphragm) for insertion. Private industrv efforts are under- 
way to market the vaginal pouch. Additional efficacy data (in 
terms of preventing pregnancy and STDs) may he sought 
comparing the vaginal pouch with the condom anil other har- 
rier methods available to women. Researchers are also inter- 
ested in understanding the behavioral components, including 
attitudes and practices, that will influence the effective use of 
the new barrier device. 

Potential Treatments for Decreasing Maternal Trans- 
mission of HIV Infection. XICHD has demonstrated, in 
collaboration with other researchers, a preliminary link be- 
tween the degree of immune dysfunction in HIV-infected 
pregnant women and the risk of transmitting HIV to the 
fetus/child: the more immune-compromised the mother, 
the more likely it is that she will transmit her infection to 
her child. Other studies are exploring the role of the pla- 
centa in the transmission of HIV from mother to child. 
XICHD also continues to participate, with the XIAID, in 
the Women and Infants Transmission Study that focuses on 
the biological determinants of maternal-child transmission 
of HIV infection. 



\K I ID li.is participated in developing two research pro- 
tocols to studv agents that max decrease the transmission ot 
111Y from pregnant infected women to their offspring. 
ACTG protocol 076 studies the effect of AZT in preventing 
or decreasing the transmission ot HIV from mother to 
fetus/child. Researchers in the ACTG 185 protocol will 
studv whether anti-HlV-specific hyper-immune globulin de- 
creases this transmission in women who are infected and re- 
ceiving AZT. 

Vaccine Development. N1CI1D has a vaccine research pro- 
gram targeting studies in the pathogenesis of and protective 
immunity to bacterial diseases, especially those ot infants and 
children. NICHD researchers are developing conjugate vac- 
cines, which combine polysaccharide antigens from bacterial 
capsules with highly immunogenic proteins, making them 
more effective with fewer side-effects. These characteristics 
make conjugate vaccines highly desirable for use in infants, 
w hose immune s\ stems are not u ell dev eloped, or in immuno- 
compromised individuals. 

NICHD researchers were the first to develop a successful 
conjugate vaccine for Haemophilus influenzae type B (Hib) for 
use in children as young as 2 months. These vaccines are being- 
credited with virtually eliminating 1 lib meningitis in this 
country. NIC! ID has successfully tested a new acellular per- 
tussis vaccine, which has been shown to be 95 percent effec- 
tive in a Swedish population, with fewer side-effects than the 
whole cell vaccine. Researchers have also developed a vaccine 
against Cryptococctts neoformans, which causes a life-threatening 
meningoencephalitis in approximately S percent of AIDS pa- 
tients. Phase 2 clinical trials arc under way to test the vaccine 
in this population. 

NIG ID researchers are using the novel conjugate tech- 
nology to develop vaccines lor bacillarv dysentery, shigel- 
losis, cholera, and hospital-acquired bacteremia. Clinical 
trials are planned to test the effectiveness of a new typhoid 
vaccine for infants and children under age 2. Studies are 
also underway that should lead to trials where mothers will 
be immunized, immediately postpartum, with a rotavirus 
vaccine to help protect breast-fed infants from serious diar- 
rhea. Perhaps most notable are the NICIID's attempts to 
use the capsular polysaccharides of Mycobacterium tuberculo- 
sis to formulate a new conjugate vaccine for pulmonary tu- 
berculosis. 

Other Behavioral Profiles for Individuals at Risk. Little is 
known about a spectrum of ingestion disorders that include 
anorexia, bulimia, overeating, and choosing hypercaloric diets 
of poor nutritional value. Learning more about the behavioral 
profiles of children and adolescents at risk for these eating dis- 
orders and understanding how the impoverished nutrient in- 
take associated with these behaviors affects brain function and 
behavior is being studied. 

Many adolescents place themselves at additional risk by in- 
gesting anabolic steroids and growth hormones to enhance 
their athletic performance and improve body physique. To 
prevent long-term physical and psychological harm, investiga- 
tors are attempting to identify the behavioral profile of indi- 
viduals at risk for these behaviors. This initiative will also doc- 
ument how ingesting supra-pharmacologic doses of anabolic 
steroids may produce behavioral effects, such as aggression, 
rage, and violence. 



Agency Innovations 



National Institute on 
Drug Abuse (nida) 

The National Institute on Drug Abuse (NIDA) is the Fed- 
eral agency with primary responsibility for research on the 
epidemiology, etiology, prevention, and treatment of drug use 
and abuse. Through its Division of Epidemiology and Preven- 
tion Research, NIDA sponsors a national research program to 
develop new scientific knowledge through national incidence 
and prevalence studies of drug use and abuse; etiologic re- 
search to identify social, environmental, and biological risk 
factors to drug use onset progression; natural history studies 
to assess the developmental course of drug use onset, progres- 
sion, and consequences; and controlled preventive interven- 
tion research to determine the effectiveness of drug preven- 
tion strategies implemented in settings such as the family, 
school, neighborhood, and workplace. NIDA transfers pre- 
vention research knowledge to prevention practitioners 
through peer-reviewed research monographs, national confer- 
ences, consensus review of research findings by scientific ex- 
perts, media-based special programs, and distribution of re- 
search findings through the National Clearinghouse for 
Alcohol and Drug Information, and NIDA's communication 
office. 



NIDA Prevention Highlights 

Epidemiologic Research. Through its national epidemio- 
logic research program, NIDA has developed innovative sur- 
vey methodologies to collect accurate information on the inci- 
dence and prevalence of drug use, abuse, morbidity, and 
mortality. The National Household Survey on Drug Abuse 
provides prevalence measures for the use of drugs reported by 
respondents aged 12 and older from households. The 1991 
survey reported that 12.8 million Americans used an illicit 
drug in the past month, a 44-percent decrease from use in 
1985; cocaine users dropped 67 percent from 5.8 million to 
1.9 million. In October 1992, this survey was transferred from 
NIDA to SAVIHSA. To gather information on subpopula- 
tions not in households, NIDA has initiated research to esti- 
mate drug use levels among people in other institutional set- 
tings and people without a fixed address. For example, the 
Washington, DC, Metropolitan Area Drug Study, which 
began in February 1991, includes 16 substudies of hard-to- 
reach populations, such as the homeless and transient, school 
dropouts, adult and juvenile offenders, pregnant drug users, 
and current drug users who may or may not be in treatment. 

Data from the 1990 High School Senior Survey indicate 
that for the first time since the survey was initiated in 1975, 
less than 50 percent (47.9 percent) of high school seniors re- 
ported having tried an illicit drug. This is a significant drop 
from the peak of 65.8 percent in 1982. The 1991 survey found 
that use of cocaine in the past year by high school seniors 
dropped from 5.3 percent in 1990 to 3.5 percent in 1991. 
Monthly use of cocaine dropped from 1.9 percent in 1990 to 
1.4 percent in 1991. Because of concerns about younger stu- 
dents, NIDA expanded the survey in the 1990-91 school year 
to include a comparable sample of students in 8uh and 10th 
grades. 

Researchers at the University of Michigan indicate that the 
decline in the use of marijuana and cocaine was associated 



with an increase in the perception of social disapproval of drug 
use and an increase in the perception of its harmful conse- 
quences. These data suggest that prevention approaches may 
have contributed substantially to downward trends in drug 



Prevention Intervention Research. NIDA supports con- 
trolled research of several drug prevention programs. Assess- 
ment ot this research using meta-analysis techniques demon- 
strates that school-based drug education programs that 
include drug information, peer resistance training, positive 
peer role models, and promotion of anti-drug social norms do 
reduce alcohol, cigarette, and marijuana use and that alterna- 
tive prevention programs appear to be effective with high-risk 
youth. Researchers test preventive strategies for their ability 
to develop and maintain (1) behavior skills, such as self-moni- 
toring, goal setting, and self-incentives, (2) cognitive struc- 
tures, such as self-efficacy and intrinsic motivation, (3) percep- 
tions of harmful consequences of drug use and abuse, (4) 
awareness of social disapproval of drug use and abuse, (5) af- 
fective and emotive impulse controls, (6) heightened concen- 
tration skills, and (7) increased interpersonal skills. 

Prevention research assesses how to structure and 
strengthen social environments to promote positive, self-regu- 
lated health behavior. NIDA researchers test strategies that 
use combinations of mass media, schools, family, peers, social 
networks, and health policies both to shape and reinforce self- 
regulated behavior change. 

NIDA supports prevention research to develop and test 
models of community and environmental change that use ex- 
isting community leaders and organizations to deliver effec- 
tive drug education messages, encourage environmental 
change, promote drug-free norms, and establish community 
prevention coalitions, particularly within high-risk neighbor- 
hoods. Prevention research attempts to determine the most 
effective techniques for community change. Research is 
needed to assess the efficacy of grassroots community coali- 
tions formed to rid their neighborhoods of open-air drug mar- 
kets and crack houses. 

NIDA supports prevention research to determine how 
drug-free policies and legislation can enhance the effects of 
comprehensive drug prevention activities in schools, families, 
and community agencies. NIDA's prevention research pro- 
gram supports methodological studies that develop and im- 
prove research designs, measurement instruments, and statis- 
tical methods to improve the scientific knowledge base for 
drug abuse prevention. Process research documents the the- 
ory, context, nature, and intensity of intervention implemen- 
tation. Outcome research assesses the efficacy of preventive 
interventions through controlled clinical trails or rigorous 
quasi-experimental research designs. Impact research tests the 
cumulative effectiveness of comprehensive drug prevention 
interventions implemented under real-world constraints and 
conditions and measured at the community level. The School- 
based Prevention Intervention Research assesses the efficacy 
of school-based drug education programs. 

Comprehensive Prevention Research in Drug Abuse. 

This research assesses the efficacy of multiple component pre- 
vention intervention programs focused on the individual, fam- 
ily, school, workplace, and community. 



nfo 



j 



Prevention '93/'94: Federal Programs and Progress 



Drug Abuse Prevention Research Centers. Research cen- 

stablished under this program design and test culturally 

ethnically sensitive theory -based preventive interventions. 

: ons of community -based leaders and multidiseiplinary 
ch groups will determine if the intervention is appropri- 
ate for the community. X1DA currently supports four preven- 
tion research centers. 

\ll)\. Prevention Research Centers. The University of 
Kentuck) Center tor Prevention Research at Lexington was es- 
tablished in 1987 n> stud\ drug abuse prevention and to design 

prevention programs. NIDA original!) funded three projects 
under the center: a study investigating novelty seeking and 
dopamine response m rats; a mass media communications study 
testing public service announcements designed tor sensation- 
seeking youth; and a community-wide sttidv in Lexington eval- 
uating the effectiveness of Project DARE, a widely replicated 
primary school-based prevention program by police officers. 
t K r er the years, the center has added projects studying drug use 
among the elderly and two community epidemiological studies 
examining drug use patterns among gay men and lesbians in 
Lexington and Louisville. The center also is conducting re- 
search on smoking cessation and evaluating three ol the Center 
tor Substance Vhusc Prevention's Community Partnership 
grants, which kind community prevention programs. 

The Tri-Ethnic Center for Prevention Research at Col- 
orado Stale University, Fort Collins, was established in 1990 
to be a national resource for drug abuse prevention research 
among three major populations — Native Americans. Mexican 
Americans, and white American youths living in Western 
States. 1 he center is concerned with prevention in both gen- 
eral ethnic populations and high-risk subpopulations: 
dropouts and students with academic problems, and delin- 
quents suffering from violence and victimization. Several pro- 
jects are examining the epidemiology of dm;; use in Mexican- 
American and Native American youths. Researchers also are 
looking at the social, psychological. .uu\ cultural correlates of 
drug use to see whether these correlates can be influenced to 
prevent drug abuse. Finally, the center is designing, imple- 
menting, and evaluating community-wide prevention pro- 
grams and special programs aimed at high-risk youths. 

The AIDS Prevention Minority Research Center, Colum- 
bia University School of Social Work. New York City, has 
been working since 1988 to reduce the spread of AIDS among 
African American and I Iispanic American youths by reducing 
dmg injection use and unsafe sexual activity. It has been con- 
ducting prevention activities among the target populations in 
all five boroughs o \ York Citj as well as in nearb) N 
Jersey. The center has been developing and testing culturally 
sensitive interventions, such as an UDS self-instructional 
guide that uses a comic-book format with a rap music rhyming 
scheme to show adolescents how AIDS is contracted and how 
they can avoid getting the disease by changing their behaviors. 
The interventions, which stress elements of ethnic pride, help 
youths to develop the problem-solving, decision-making, cop- 
ing, and communications skills they need to respond to high- 
risk situations. 

The .Minority Drug Abuse Prevention Research Center, 
Cornell University -Medical College. New York Citv. XIDA's 
newest center, was funded at the end of 1991 to explore ways 
to prevent drug abuse among minoritv populations. The cen- 
ter formalizes a long-standing collaborative relationship 



among the AIDS prevention center and the American Health 
Foundation, a nonprofit corporation with extensive experi- 
ence in health promotion research. Initially, these research 
groups will take promising prevention strategies and test and 
refine them for African American and Hispanic American 
youths. In subsequent years, the research focus will broaden to 
include both younger and older age groups and other minori- 
ties, such as Asian Americans. Interventions will be delivered 
initially through community organizations, housing projects, 
and homeless shelters. 



National Institute on Deafness 
and Other Communication Disorder 
(nidcd) 

The National Institute on Deafness and Other Communica- 
tion Disorder conducts and supports research and research 
training on normal mechanisms as well as diseases and disorders 
ot hearing, balance, smell, taste, voice, speech, and language. 
NIDCD achieves us mission through a wide range of research 
performed in its own laboratories, a program of research grants, 
individual ami institutional research training awards, career de- 
velopment awards, center grants, and contracts to public and 
private research institutions and organizations. NIDCD also 
conducts and supports research ami research training that is re- 
lated to disease prevention and health promotion. N1DC1) ad- 
dresses special biomedical M'id behavioral problems associated 
with people who have communication impairments or disor- 
ders. NIDCD supports efforts to create devices that substitute 
lor lost and impaired sensory and communication functions. 
NIDCD is committed to understanding how certain diseases 
may affect women, men. and members of minority populations 
differently. 1 ensure public dissemination ot research infor- 
mation, NIDCD has established a mandated national clearing- 
house ot information and resources on the normal and disor- 
dered mechanisms of human communication. The NIDCD 
Clearinghouse collects information on NIDCD's seven basic 
research areas and disseminates it to health professionals, pa- 
tients, industry, and the public. 

NIDCD Prevention Highlights 

Genetic Hearing Impairment. For the first, a chromosomal 
location ot a gene for nonsyndromic hearing impairment has 
been found. A team ot investigators has located the gene re- 
sponsible for transmission of a form of hearing impairment 
using a large kindred in Costa Rica in whom hearing impair- 
ment develops late in childhood and becomes severe between 
the ages ot 30 and 40. The gene is on the long arm of chromo- 
some 5. Further chemical characterization of the gene and 
studies of its protein products may open new vistas for preven- 
tion as the expression of the gene is studied for its effects 
throughout the life cycle of the auditory sensory cells. 

Presbycusis. L'nderstanding neurochemical contributions to 
the pathogenesis of this progressive hearing loss disease has 
important clinical implications for presbycusis patients since 
chemical faults may underlie both peripheral and central 
manifestations. In studies using aged rats as an animal model, 
investigators found lower levels of the neurotransmitter 



Agency Innovations 



gamma-aminobutyric (GABA) and its receptors in auditory 
nuclei. Of special interest are the mechanisms for these 
chemical imbalances, with implications for both remediation 
and prevention. 

Language Disorders in Children. Approximately two-thirds 
of children identified as late or slow talkers before the age of 2 
show continued delays in expressive language at age 3, and 
more than half see those deficits persist to age 4. Such findings 
indicate that while some children do outgrow their delays in 
the preschool period, a substantial portion do not. It is known 
that the risk of learning disabilities for children with language 
delays at age 4 is very high. Thus, for that half of the late talk- 
ers population who do not outgrow their slow start by age 4, 
die chances of having serious problems in learning to read, 
write, and spell are great. Such findings strongly suggest that 
failure to begin talking by age 2 constitutes a hazard that ought 
to be addressed through early intervention, which may serve as 
a preventive measure for avoiding later learning disabilities. 

Balance and Vestibular Disorders. The vestibular system, 
working in concert with other sensory and motor systems of 
the human body, controls the postural adjustments that the 
organism must make to maintain balance. Research is ongoing 
to understand the adaptive capabilities of the postural and vi- 
sual stabilizing reflexes in patients with imbalance in order to 
guide interventions aimed at reducing disabilities associated 
with vestibular disorders (e.g., unsteadiness, falls, degraded vi- 
sual acuity). The beneficial effects of even brief periods of cer- 
tain physical exercises on the postural stability of patients 
recovering from unilateral vestibular loss have been demon- 
strated. The position of the head relative to the axis of head 
rotatory movement has been shown to influence adaptation of 
the vestibulo-ocular reflex. In addition, a new quantitative 
technique has been devised to study the effects of interven- 
tions (e.g., induced vestibular reflex adaptation, vestibular ex- 
ercises) on gaze stability. These advances will have important 
implications for planning programs of physical rehabilitation 
for patients with balance and vestibular disorders. 

Noise-Induced Hearing Loss. Noise-induced hearing loss, 
which is often preventable, affects some 10 million Americans. 
The National Institute on Deafness and Other Communica- 
tion Disorders produced a videotape and teacher's guide "I 
Love What I Hear!" for use with third through sixth graders 
designed both as a prevention message and as an introduction 
to the biology of hearing. To understand the mechanism of 
damage and the individual response to noise, investigators 
successfully grew auditory sensory cells from the basilar 
papilla, the hearing organ of the chick. Studies were con- 
ducted to elucidate the relationship between length of noise 
exposure and severity of damage, and the ability of the basilar 
papilla to regenerate sensory cells. 



National Institute of Diabetes and 
Digestive and Kidney Diseases 
(niddk) 

The National Institute of Diabetes and Digestive and Kid- 
ney Diseases is responsible for a wide variety of research re- 



lated to diabetes, endocrine, and metabolic disorders, diseases 
of the liver and digestive tract, nutrition, and diseases of the 
kidney, urinary tract, and blood. 

NIDDK Prevention Highlights 

Insulin-Dependent Diabetes Mellitus (IDDM): Progress 
Towards Primary Prevention. Progress has been made in 
seeking molecular genetic clues to IDDM; nevertheless, the 
genetic component to IDDM does not preclude a role for en- 
vironmental variables that may precipitate this autoimmune 
disease, and which may be susceptible to preventive measures 
in those at high risk for development of IDDM. For example, 
similarities have been noted between components of insulin- 
secreting beta cells in the pancreas and certain viruses. In ad- 
dition, a lower risk of IDDM has been noted in children breast 
fed for longer periods without breast milk substitutes. Anti- 
bodies to cows' milk albumin are more likely in children with 
IDDM, and these react with a beta-cell-specific surface pro- 
tein. These findings suggest that elucidation of the initiating 
antigen(s) in IDDM will further the development of specific 
preventive measures. It is already known that oral administra- 
tion of insulin can delay or prevent onset of diabetes in animal 
models of IDDM, and the search is on for other beta cell com- 
ponents with a similar potential. 

Noninsulin-Dependent Diabetes Mellitus (NIDDM): 
Risk Factors and Preventive Strategies. High rates of obe- 
sity in minority populations correlate with the disproportion- 
ate impact of Type II diabetes (NIDDM) in these groups. In 
addition, the level of physical activity correlates inversely with 
die risk of NIDDM. The effect of exercise is most beneficial 
to those who are most obese. Preventive intervention with 
diet, physical activity, and behavior modification holds 
promise lor those at risk for NIDDM based on genetic predis- 
position, insulin resistance, and reduced insulin synthesis. Al- 
though the research evidence for genetic susceptibility to 
NIDDM in minority groups in strong, it seems clear that dia- 
betes is associated with increased body weight, abdominally 
distributed fat, and physical inactivity. 

Obesity Development and Its Implications for Preventive 
Medicine. Obesity is a risk factor in 5 of the 10 leading causes 
of death in the United States, including the top 3 (heart dis- 
ease, cancer, stroke). Importandy, these nutrition-related ill- 
nesses are preventable, perhaps even reversible, through be- 
havioral and dietary means. One of the dangers of significant 
weight loss is gallstone formation; the prevention of gallstones 
is an active area of research. 

Diabetes Research of Special Importance to Minority 
Populations. The report of the DHHS Secretary's Task 
Force on Black and Minority Health identified diabetes and its 
complications as one of six health problems responsible for ex- 
cess mortality among U.S. minority populations. Numerous 
applied and clinical studies are expected to provide the tools to 
reduce the excessive diabetes morbidity and mortality among 
minority populations — all of whom are disproportionately af- 
fected by the disease. The role of environmental factors in di- 
abetes is well established and the familial tendency for Type II 
diabetes could be due in part to intra-familial similarity in dia- 
betes-facilitating patterns. Successful modification of lifestyle 



^^ 



Prevention '93/'94: Federal Programs and Progress 



uD 



(actors in high-risk populations can help greatly in the reduc- 
tion of diabetes morbidity and mortality. 

Studies With the Pima Indians. For more than 25 years 
NIDDK, and recently other XII 1 institutes, have conducted 
an extensive research program on Type 11 diabetes in the Pima 
Indians in the Gila River Reservation in Arizona, a community 
that has the highest rate of diabetes in the world. A cross-sec- 
tional and longitudinal stud) ongoing since l n S2 is now 
recording the metabolic characteristics that are predictive of 
the development of diabetes in this group. It documents the 
sequence oi metabolic events that occur during the transition 
from normal to impaired glucose tolerance and thence to dia- 
betes. Data obtained to date suggest that insulin resistance is a 
primary abnormality predisposing Pima Indians to develop 
impaired glucose tolerance; the development of frank diabetes 
occurs with subsequent pancreatic failure. 

\ll)l)k Initiatives for Dnbetes R.se.u.h in Minorities. 

The NIDDK is taking a number ol steps to intensify research 
on Type II diabetes, with particular emphasis on minority 
populations. In 1993 close to SI million will be expended to 
support over 30 new planning grants to increase research on 
diabetes in minority populations. NIDDK has launched a 
major new obesity research initiative. NIDDK. is currently 
planning with members ol the National Diabetes Advisory 
Board an initiative for a major, multicenter clinical trial on 
Type II diabetes with emphasis on minoritv populations. 

Other Diabetes Prevention Initiatives. NIDDK support of 

diabetes research ami training centers has historicall) in- 
cluded community education .\nA intervention programs, and 
support ot clinical trials. Training programs among minori- 
ties are emphasized. Components of this effort include (h 
clinical trials of non-drug treatment and prevention of 
NIDDM: prospective randomized studies of the efficacy of 
weight loss and fitness development: (2l body weight control 
interventions lor the prevention and treatment ot diabetes in 
minority populations; (3) collaborative research with the In- 
dian Health Service on diabetes in Native Americans and 
Alaska Natives: (4) drug development tor amelioration or 
prevention ot NIDDM complications, with subsequent clini- 
cal trials: (5) clinical studies ot variables associated with in- 
creased diabetes prevalence in minoritv or other racial/ethnic 
groups; (6) studies of diabetes in Native Hawaiians; anil (~) 
research training of physicians from under-represented mi- 
noritv groups. 

Epidemiology, Data Systems, and Diabetes Data Group. 
These efforts encourage epidemiologic research, develop 
bases tor prevention programs through risk factor modifica- 
nd assess the effectiveness of preventive regimens 
through clinical studies. .Minority populations are a key focus 
of attention. 

National Task Force on Prevention and Treatment of 
Obesity. This Task Force was established by the NIDDK in 
1991 to provide authoritative information about what is 
known and not known about obesity; it serves a professional 
educational function as well as a public education function. 
The Task Force reports administratively to the National Di- 
gestive Diseases Advisory Board. 



On November 3. 1992, announcement was made of the 
award of three P30 (C lore Center) Obesity/Nutrition Research 
Outer grants, with a total budget of S- .2 million. At the Uni- 
versity ot Vermont, environmental interactions with meta- 
bolic regulation will be stressed. Several centers in Boston will 
collaborate to study obesity and energy metabolism and to de- 
velop education and training programs. At the Universit) of 
Pittsburgh, attention will locus on the prevention ot obesity, 
and especially w ill locus on the acquisition of eating ami exer- 
cise habits, anil on the treatment of obesity, especially by be- 
havioral modification methods. 

The Ohesuv Information Resource Center coordinates ex- 
isting efforts and makes use of materials related to obesity ed- 
ucation and interventions funded by Nlll, PI IS, and other 
government, State, .\n^\ local and private sector programs 
rather than duplicating such materials. Pact Sheets on "Binge 
Eating Disorders" and on "Important Elements ol a Sate and 
Successful \\ eight Loss Program"' were produced. In response 
to Congressional and other interest in assessment of weight 
loss programs and systems, a Technology Assessment Confer- 
ence on I lea I di Effects ot Voluntary Weight I oss Efforts was 
held in March P">: at Nil I. Other activities include a Mil 
Workshop on the Pharmacologic Treatment of Obesity, 
NIDDK Workshop on Physical Activity and Obesity, Posi- 
tion Paper on Very Low Calorie Diets, and Paper on Dieting 
and Gallstones. Position papers on Health Benefits and Risks 
ol Weight Loss .\nd on Prevention ol Obesity are in early 
stages ol formulation. A joint Request for Applications on 
Childhood and Adolescent Obesity from NIDDK and the 
National Institute of Child Health and Human Development 
(N1CHD) was issued on February 16, 1990. In addition, a 
conference on Prevention and Treatment of Childhood Obe- 
sity has been funded and scheduled. A scientific meeting on 
research needs on Obesity Treatment was held in early June 
1993 in New York. 

NIDDk I A [992 Clinical Trials on Obesity. Controlled 
clinical trials are underway involving Obesity Treatment: Self- 
Management versus Dependence Models; Long-Term Out- 
come of Obesity Treatment in Minority Women; Weight 
Loss Maintenance in Severe Obesity; Low Fat Ad Libitum 
Diet and Weight Loss; and Gallstone Prevention During 
Weight Reduction. 

Gastritis and Peptic Liters: The Role of Helicobacter Py- 
lori. The spiral organism II. pylori is found in the stomach of 
manv adults but is strongly associated with chronic active gas- 
tritis and peptic ulcer. Investigators supported by NIDDK 
have now shown that they can prevent virtually any recurrence 
of peptic ulcer disease by eradicating the H. pylori infection uti- 
lizing the combination of the antibiotic tetracycline, metron- 
idazole (Flagyl), and bismuth subsalicylate (Pepto-Bismol). 

Benign Prostatic Hyperplasia (BPH): The Role of 
Growth Factors. NIDDK-supported researchers have shown 
there are high concentrations of basic fibroblast growth factor 
in the adult prostate gland in hyperplastic regions, whereas the 
levels in normal tissue are low. In addition, specific growth 
factors from the testes are secreted in the semen. Testis-de- 
rived growth factor may have a direct role in the initiation or 
stimulation of BPH, and further research on this effect should 
suggest ways to prevent or control this condition. 



Agency Innovations 



Professional and Public Education. In September 1992, 
NIDDK sponsored a Consensus Conference on Gallstones 
and Laparoscopic Cholecystectomy. Another Consensus Con- 
ference was held in December 1992 on Impotence. Planned 
for the 1993-1994 period are conferences on Dialysis Morbid- 
ity and Mortality and on Peptic Ulcer and Helicobacter py- 
lori. In addition to the clearinghouse on obesity, NIDDK op- 
erates clearinghouses on diseases related to obesity, such as 
diabetes, digestive diseases, and kidney disease of diabetes. 
Several publications have been issued which explain the preva- 
lence of NIDDM. 



National Institute of Dental 
Research (nidr) 

The broad mission of NIDR is to improve the oral health of 
the American people. NIDR supports and conducts research 
and research training on oral diseases and disorders and on 
normal patterns of oral tissue growth, repair, and mainte- 
nance. The NIDR promotes prevention-related research and 
ongoing studies are aimed at developing and testing new pre- 
vention strategies as well as identifying factors influencing the 
adoption and implementation of preventive strategies. 

NIDR Prevention Highlights 

NIDR Research and Action Program. Through the NIDR 
Research and Action Program To Improve the Oral Health of 
Older Americans and Other Adults at High Risk, nine re- 
search contracts are underway addressing oral health issues of 
adults. Three studies are investigating risk factors for tooth 
loss among middle-aged and older adults; other studies in- 
clude a 2 -year intervention study comparing strategies for 
preventing gingivitis and dental caries in older adults con- 
ducted at two public health department dental clinics serving 
lower income, inner city populations; a longitudinal study ex- 
amining risk factors for oral diseases among older adult dia- 
betic patients; a longitudinal investigation of tooth loss and 
periodontitis among Native Americans with diabetes in the 
Gila River Indian community; a study of the effectiveness of 
group behavioral intervention programs for older periodontal 
disease patients in health maintenance organizations; a cross- 
sectional and longitudinal analysis of factors associated with 
alveolar bone loss in aging men; and a study investigating the 
effectiveness of topically applied fluoride to prevent root and 
coronal caries in adults age 45 and older. 

NIDR is active in the PHS Oral Health Coordinating 
Committee chartered by the Assistant Secretary for Health 
and chaired by the Chief Dental Officer. The mission of the 
committee is to facilitate action in the prevention of oral dis- 
eases among adults, to help maintain and enhance programs 
addressing oral health among children, and to coordinate ac- 
tivities in relation to HEALTHY PEOPLE 2000. 

NIDR is active in Oral Health 2000, an initiative organized 
by a private foundation, The American Fund for Dental 
Health, which is recognized in a memorandum of agreement 
with PHS. This public and private collaborative enterprise 
unites government, foundations, consumer interest groups, 
industry, and health professionals in the largest public educa- 
tion/service program in oral health ever undertaken. The goal 



of Oral Health 2000 is to improve oral health by raising public 
awareness of the problems of oral diseases and promoting pre- 
vention. A major focus is educating the public to accept and 
understand that total oral health is indispensable to general 
health. The initiative also highlights the needs of older adults 
and high-risk populations. 

Minority Oral Health. NIDR awarded six grants, with sup- 
plemental funding from the National Center for Research Re- 
sources, to support the development of Regional Research 
Centers in Minority Oral Health. The aim of these 3 -year de- 
velopmental grants is to enable minority dental schools or 
dental schools serving large minority populations to form the 
alliances and organizational structure necessary to compete 
for 5 -year research center grants to be awarded in 1995. 

NIDR is conducting a phased feasibility study of a com- 
munity-based health promotion strategy in a minority com- 
munity. The proposed research will focus on one geographi- 
cally defined community with an internally diverse minority 
population to assess the feasibility of a community defining 
and managing its oral health. The proposed research will ad- 
dress both outcomes and process. Research questions will in- 
clude the following: Can a community define its oral health 
problems? Can existing and new resources (e.g., facilities, 
health care providers, payment systems) be identified and 
mobilized to address and correct identified problems? Can 
the community implement an oral health promotion strat- 
egy? Can awareness of, knowledge of, and attitudes toward 
oral health be improved? Can oral health behaviors (e.g., self 
care, risk behaviors, dental visits) be changed? Can oral 
health status be improved as a result of a community-based 
oral health promotion approach? Can the changes in oral 
health and behaviors be sustained past a period of active in- 
tervention? What is the efficacy of using community re- 
sources to address oral health problems within the context of 
other life-threatening medical or social conditions in a mi- 
nority community? 

NIDR is collaborating in research to improve the oral 
health of Native Americans. The Pima Indian populations in 
Sacaton, Arizona, have one of the highest rates of NIDDM in 
the United States. NIDDM renders these individuals suscep- 
tible to extensive and severe periodontal disease, which leads 
to rapid tooth loss at an early age. Periodontal disease treat- 
ment is complicated by slow healing and impaired immune re- 
sponses in NIDDM patients. To overcome these obstacles 
and to determine the most effective treatment for Native 
Americans with NIDDM, the Indian Health Service (IHS) 
and NIDR have developed a model treatment program that 
can be adopted in other IHS dental clinics. Patients are receiv- 
ing thorough treatment for their periodontitis, and some will 
be further treated with a antimicrobial to test its effectiveness 
in controlling recurrence of the disease. 

Data from the 1986-1987 NIDR Survey of the Oral Health of 
U.S. Children were used to identify cases of early-onset peri- 
odontitis for follow-back study. Half of the study population is 
black; many others are Hispanic. The collection of biological 
specimens and their microbial assays provides for analysis of 
biologic and non-biologic pathogenic risk markers and host- 
resistance factors for individuals both with and without juve- 
nile periodontitis. 

NIDR is evaluating the determinants of permanent tooth 
loss in a study population that consists mainly of blacks and 



^ 



Prevention '93/94: Federal Programs and Progress 



^fe 



Hispanics. A theoretical model to explain factors influencing 
choice between extraction and alternatives is being developed. 
X1DR is sponsoring a study to determine the association 
between known or suspected risk factors and the occurrence of 
oral cancer in the Commonwealth of Puerto Rico, a geo- 
graphic site that has consistently shown an unusually high in- 
cidence or' oral cancer. Findings of the study could result in 
the development and application of interventions to reduce 
the incidence and mortality of oral cancer in this and other 
populations. 

Biomarkers for Prevention and Early Intervention. XIDR 
is assessing the potential use of saliva or other oral tissue sam- 
ples as diagnostic indicators of osteoporosis and oral or sys- 
temic diseases. NIDR is also investigating saliva as a diagnos- 
tic marker in individuals at risk for disease, e.g.. \11)S. as well 
as the presence of drugs and hormones. In still another appli- 
cation, XIDR is collaborating with XCI researchers on a 

study of the use of saliva to assess fat intake among women en- 
rolled in the Women's Health Trial Minority Feasibility 
Study. Assessment ot dietary tat intake by means ol salivary 
analyses affords an attractive alternative to more conventional 
procedures. By complementing an existing dietary interven- 
tion trial with studies ol saliva, the XIDR is making a signifi- 
cant contribution to the area ol molecular epidemiology anil 
disease indicators. 

Fluoride Efficiency and Efficacy. In light of the current de- 
cline m caries prevalence, experts are re-examining the effi- 
cacy, dosage level, and cost effectiveness ot fluoride. The issue 
ol combined sources ol fluoride (e.g., food, drinking water, 

dentifrices, ami other dental products) in relation to appropri- 
ate dosages lor prevention are being addressed in research. 
The XIDR has undertaken several projects to further eluci- 
date ami define current interrelations between denial canes. 
dental fluorosis, and various concentrations of fluoride in 
drinking water and other sources of fluoride. 

One study of dental fluorosis was begun under contract in 
July 1992 to assess the prevalence and seventy of dental fluo- 
rosis in the early erupting permanent teeth ofschool-age chil- 
dren residing in the Portland, .Maine, area. These children 
have used dietary fluoride supplements since birth in accor- 
dance with the dosage schedule currently recommended by 
the American Dental Association. This study will provide es- 
sential information needed to clarify whether the current stan- 
dards for fluoride supplementation are still appropriate in 
terms ot caries prevention and fluorosis. 

Sealants. The XIDR remains concerned about the low uti- 
lization of dental sealants for preventing tooth decay among 
children, particularly those at high risk. .Much efficacy ami 
some effectiveness research has been done on sealants. It is 
widely accepted that sealants prevent decav and questions of 
long-term effectiveness are being answered. However, the 
questions of policy and professional acceptability remain im- 
portant barriers. In the current economic climate, the ques- 
tion of returns on investment are critical. For this reason, 
XIDR is undertaking demonstration research that will assess 
the cost and benefits of sealant programs, particularly among 
children at high risk. The central research question is whether 
the value of providing dental sealants to selected populations 
merits the investment of limited resources. Value will be as- 



sessed in terms ot levels ot health and satisfaction, reduced po- 
tential tor future treatment needs, reduced risks ot disease se- 
quelae, enhanced functional capacity, cost savings, and re- 
duced time missed from school, work, or social activities as a 
result of dental treatment averted. 

Genetically Engineered Vaccines. Major progress is occur- 
ring in the development of vaccines for dental caries, certain 
periodontal diseases. Herpes simplex virus infections ami 
other oral infections using genetic engineering techniques. 
These new -generation vaccines use highly purified molecules 
isolated from bacteria or viruses as the immunizing agents, 
supplying them in the form of easv -ro-svvallow vaccines. Mon- 
oclonal antibodies to decav -causing bacteria are also being de- 
veloped. These antibodies can be given to individuals at high 
risk lor tooth decav to boost their own immunity to disease. 
This passive immunity approach, as well as several candidate 
vaccines, are ready lor testing in clinical trials. 

In other research. XlDR-supported scientists have shown 
that the major decay-causing bacteria are not normally found 
in the mouths of infants but are generally transmitted from 
mother to infant in the course of development. Indeed, scien- 
tists have identified a definite time period, from 19-28 months 
ol age. when this transmission is most likely to occur. 

Dental Plaque. The molecular scaffolding of dental plaque 
consists ot a water-insoluble polymer of glucose, known as 
mutan, which is synthesized by bacteria that cause tooth 
decav . S. Vllltans and .V. sanguis inhabit the mouths of humans. 
\. nmtans produces mutan ami is know n lo cause caries. .V. san- 

ii the other hand, docs not produce mutan ami its pres- 
ence is associated with good oral health. Plaque can be re- 
moved from human teeth by an enzyme known as mutanase, 
which degrades the mutan polymer to glucose. Researchers 
are cloning the gene encoding tor the fungal mutanase and 
plan to put it into .V sanguis. When the genetically engineered 

.,.7/1 is placed in the mouth, they expect that the enzyme 
will be secreted and inhibit the accumulation of dental plaque 
and consequently prevent dental canes. 

Vitamin Supplementation and Oral Cancer Prevention. 

Investigators are conducting animal studies and a non-ran- 
domized clinical trial on the effects of beta carotene on carci- 
noma. In the animal study, squamous cell carcinoma was in- 
duced chemically and beta carotene reduced the number of 
lesions significantly. In a patient study, partial or complete 
resolution of "I percent of lesions occurred. Initial findings 
indicate that dietary supplementation with vitamins C and E is 
associated with a decreased likelihood of developing cancer. 
Ongoing research is testing vitamins individually and in com- 
bination at varying dosages. 

Risk Factors for Periodontal Diseases. XIDR-supported 
periodontal research centers are conducting a number of clini- 
cal studies assessing environmental, microbiological, and host 
risk factors for disease so that appropriate preventive interven- 
tions can be developed. One study of 803 subjects indicated 
that smokers were 7 times more likely to have periodontal 
pockets of 4 mm or greater than non-smokers. This finding 
was unrelated to gender, the time since the last prophylaxis, 
the periodontal or gingival indices, or the bacterial species in 
the sub-gingival plaque. In a related project, the investigators 



Agency Innovations 



found that 92 percent of a group of refractory periodontal dis- 
ease patients were smokers and had detects in polymorphonu- 
clear leukocyte phagocytic function. Thus smoking, which in 
the past has been strongly associated with abnormal changes 
in the mucosa, appears to be a significant risk factor tor peri- 
odontal diseases and will continue to be investigated. 

Science Transfer. A contract to develop a National Oral 
Health Information Clearinghouse to provide information to 
individuals and organizations was let in 1993. In conjunction 
with the establishment of the clearinghouse, a national search to 
identify available patient and professional literature and audio- 
visuals in the oral health field was conducted. The information 
from the survey constitutes the initial database of resource ma- 
terials for the clearinghouse. The developing oral health data- 
base was approved tor inclusion in die Combined Health Infor- 
mation Database (CHID), a computer network of 17 federally 
operated subfiles that provide health information and education 
resources to patients, professionals, educators and the public. 



National Institute of Environmental 
Health Sciences (niehs) 

The National Institute of Environmental Health Sciences 
conducts and supports research, training, information dissemi- 
nation, and other programs with respect to factors in the envi- 
ronment that affect human health, directly or indirectly. To this 
end, NIEHS investigates the effects of chemical, physical, and 
biological environmental agents on human health. Program 
output is intended to aid those agencies and organizations, pub- 
lic and private, responsible for developing and instituting regu- 
lations, policies, and procedures intended to prevent and reduce 
the incidence of environmentally induced diseases. 

NIEHS Prevention Highlights 

Biomarker Research. Recent advances in molecular biologi- 
cal techniques have resulted in significant new developments 
in the investigation of biological markers of environmental ex- 
posure and effect. NIEHS-supported scientists are studying 
techniques tor measuring cumulative exposure to metals and 
other agents; developing biomarkers for toxicant-induced 
DNA damage; and determining components of receptor-me- 
diated toxicity. All of these techniques have the potential to 
identify hazardous environmental or occupational exposures 
before clinical effects appear, and can be used to establish ex- 
posure limits to minimize health risks and prevent disease. 

Lead Exposure Research. Lead exposure causes serious and 
permanent adverse human health effects such as central ner- 
vous system damage and renal failure. Numerous reports from 
NIEHS-supported scientists have demonstrated that lead ex- 
posure in children, even at low levels, adversely affects neu- 
robehavioral function. One long-term NIEHS study of chil- 
dren found that elevated lead levels in infants are associated 
with later-occurring reading disabilities, delinquency, and re- 
duced high school graduation rates. NIEHS scientists are also 
directing basic research aimed at further understanding the 
mechanisms of lead toxicity and lead mobilization during 
pregnancy. 



NIEHS recently initiated a clinical trial of succimer, a 
promising chelating agent for reduction of elevated blood 
lead. In combination with lead-abatement measures, this 
chelation treatment will be evaluated for its ability to reduce 
blood lead levels and, eventually, to prevent the neurobehav- 
ioral effects of lead poisoning. These programs, as well as 
other lead abatement and lead poisoning control strategies de- 
veloped by the Environmental Protection Agency and the De- 
partment of Housing and Lfrban Development, are aimed at 
preventing childhood lead poisoning, particularly in those 
most at risk, the inner-city poor. 

National Toxicology Program's Toxicology and Carcino- 
genesis Studies. NIEHS houses the largest single component 
of the National Toxicology Program and initiates a number of 
2 -year chronic and prechronic studies each year. Each study is 
peer-reviewed and the results made public. Chemicals are se- 
lected for study on the basis of potential human exposure, 
level of production, and chemical structure. 

In 1992, 13 chronic studies were peer reviewed, and 4 
showed clear evidence of carcinogenicity in 1 or 2 species of 
rodents of both sexes. The 4 chemicals determined to be car- 
cinogenic were C.I. Direct Blue, a dye; oxazepam, a tranquil- 
izer; a polybrominated biphenyl mixture (Firemaster FF-1), 
used as a flame retardant; and 2,3-dibromo-l-propanol, a 
chemical intermediate for flame retardants, insecticides, and 
pharmaceuticals. The results ot these reports will be used by 
other Federal agencies to regulate the use of these chemicals 
and to require necessary safety standards and devices to reduce 
or prevent potential exposure and disease in workers. 

Superfund Basic Research Program. NIEHS funds several 
projects related to prevention research as part of the basic re- 
search program under Superfund. These projects address pub- 
lic health in the area of environmental remediation, with the 
goal of preventing exposure and subsequent disease. One such 
initiative concerns the health effects of combustion by-prod- 
ucts, in which combustion engineers are collaborating with 
biomedical researchers to identify the major toxicants pro- 
duced by combustion. The project includes research to under- 
stand the processes responsible for the formation and destruc- 
tion of potentially hazardous combustion by-products and to 
develop chemical and physical technologies to reduce their 
amount and toxicity. 

A second Superfund-sponsored initiative supports research 
on biodegradation of hazardous agents. These research pro- 
jects focus on understanding particular metabolic pathways 
that are important in the biotransformation process for envi- 
ronmental compounds, mixtures, and metals. An understand- 
ing of these processes will allow researchers to manipulate 
them at the molecular level; the goal is not only to increase the 
rate at which biodegradation occurs naturally, but also to 
broaden the process to include activity against a wider variety 
of environmental toxicants. 

Hazardous Waste Worker Training Program. The Super- 
fund Amendments and Reauthorization Act of 1986 autho- 
rized NIEHS to establish an assistance program tor training 
and education of workers engaged in hazardous waste re- 
moval, containment, and emergency response. The purpose of 
this training is to educate hazardous waste workers and super- 
visors on proper safety and cleanup procedures in the event of 



wD 



Prevention '93/'94: Federal Programs and Progress 



© 



a spill of hazardous material. There are currently 18 grant re- 
cipients in the NIEHS program, representing approximately 
70 institutions. During the first years (1987-1990) of the pro- 
gram, more than 250,000 workers received training in over 
8,000 classroom and hands-on courses, accounting for almost 
4 million hours of actual training. Completion of this training 
permits workers to use proper methods to contain and clean 
up accidents involving hazardous materials in a manner that 
will prevent exposure and injury. 

Environmental Equity. Environmental equity or environ- 
mental justice is a newly emerging social issue that links race, 
socioeconomic status, and occupation to exposure to haz- 
ardous environmental agents. A number of studies have estab- 
lished that minority populations are more likely to suffer ele- 
vated levels of such environmentally related or potentially 
environmentally related disease as lead poisoning, certain can- 
cers, renal disease, neurological impairments, and asthma. 
NIEHS is in the forefront of the effort to develop a research 
strategy to substantiate the association between environmental 
exposure and their presumed, but as yet unproven health out- 
comes. In this effort, NIEHS has joined with other Federal 
agencies and actively solicited the input of academic and grass- 
roots leaders of communities of color to identify data gaps and 
to develop the research agendas needed to address the health 
effects of such environmental exposures. These may include 
basic and epidemiologic research aimed at identifying links 
between exposures to environmental agents such as grain 
dusts, pesticides, and industrial and petrochemical plant emis- 
sions, with subsequent disease or dysfunction. Additionally, 
NIEHS programs are targeted to improve the diversity in 
trained environmental health professionals by encouraging 
minorities to enter environmental health professions. 



National Institute of General 
Medical Sciences (nigms) 

The mission of the National Institute of General Medical 
Sciences (NIGMS) is to support research and research train- 
ing in the basic biological sciences. Projects supported by the 
NIGiMS are largely investigator-initiated, and they provide 
the foundation for subsequent disease-targeted studies sup- 
ported by the other components of the NTH. 

NIGMS Prevention Highlights 

Individual Responsiveness to Drugs and Prevention of 
Toxicity. NIGMS supports basic pharmacological research to 
identify factors and clarify the mechanisms involved in the safe 
use of drugs. Research has been conducted to elucidate the en- 
zymatic mechanisms of anesthetic bioactivation and the clini- 
cal pharmacology ol anesthetic toxification. This knowledge 
may be used to identify patient populations and individuals 
potentially at risk for anesthetic toxicity. Clinical strategies 
may then be devised lor avoiding specific anesthetic agents or 
administering protective adjuvants. 

Pathogenesis and Prevention of Multiple Organ Failure. 

Multiple organ failure (MOF) is a major problem following 
traumatic injury. It is the leading cause of mortality and mor- 



bidity in trauma and burn patients. Its etiology has remained 
elusive, but inflammation seems to play an important role in 
its pathogenesis. The NIGMS supports several research pro- 
jects to elucidate the antecedents of MOF. Through research 
on such factors as intestinal injury and the pathogenesis of 
post-traumatic sepsis, a rational basis may be provided for the 
clinical prevention and treatment of MOF. 

Prevention of Wound Infection. One of the most powerful 
means that clinicians possess to enhance early wound healing 
and resistance to infection lies in the control of oxygen deliver} 7 
via blood perfusing the injured tissue. NIGMS-supported in- 
vestigators are studying specific impediments to oxygenation 
and testing strategies to overcome these impediments. These 
studies are expected to provide the basis for simple and inex- 
pensive changes in strategies of surgical care that will lead to 
major reductions in infections and other wound complications. 



National Institute of Mental 
Health (nimh) 

The mandate of the National Institute of Mental Health 
(NIMH) is to improve understanding of the cause, diagnosis, 
treatment, control, and prevention of mental illness. This is 
accomplished through the conduct and support of behavioral 
and biomedical research, health services research, research 
training, and health information dissemination. NTMH pre- 
vention activities are conducted through both intramural and 
extramural units. In 1993, a third national prevention research 
conference was sponsored and a contract to the Institute of 
Medicine to study prevention research was completed. 

NIMH Prevention Highlights 

Acquired Immunodeficiency Syndrome (.AIDS). AIDS is a 
disease with substantial psychological and behavioral impact. 
Curbing the transmission and spread of HIV requires behav- 
ior change. Moreover, behavior is a co-factor in the modula- 
tion of immune function and in the progression from infection 
to disease. Research on the primary prevention of MDS 
through changing high-risk behavior is a priority. Thus, the 
NIMH MDS prevention effort focuses on the determinants of 
risk behaviors, the development and assessment of programs 
to achieve and maintain behavior change, and the efficacj ol 
various organizations in implementing prevention programs. 
Both MDS Research Centers and investigator-initiated stud- 
ies are important mechanisms for accomplishing multidiscipli- 
narv research on behavioral, neuropsychological, neuropsy- 
chialric, and mental health aspect-- ol \IDS 

Prevention of Conduct Disorder. Conduct disorder is de- 
fined as a pattern of persistent, defiant, and oppositional be- 
haviors that ignore the rights of others. Mure commonly, it is 
known as antisocial, delinquent aggressive, acting out, or ex- 
ternalizing behaviors. This disorder is the most frequent rea- 
son for referral of children to "inpatient mental health ser- 
vices. Because conduct disorder is common and predictive ol 
adult antisocial behavior and substance abuse, new research on 
preventive approaches for high-risk children has become a 
priority. Current studies focus on changing cognitive 



Agency Innovations 



processes underlying social behaviors, fostering academic and 
social skills, and improving behavior management. 

A new grant program of prevention research demonstra- 
tions aimed at conduct disorders was initiated at the end of fis- 
cal year 1990. Three awards were made. The first award was 
for a combined school-based intervention and summer camp 
for first and second grade children and their parents. The in- 
tervention will be tested at four sites: Durham, North Car- 
olina (Duke University), Nashville, Tennessee (Vanderbilt 
University), rural Pennsylvania (Pennsylvania State Univer- 
sity), and Seattle, Washington (University of Washington). 
The second award was for a school-based intervention pro- 
gram for at-risk minority children in high-crime areas of 
Chicago (University of Illinois, Chicago). The third grant 
project combines a daily skills training and classroom achieve- 
ment system with peer communication groups for high-risk 
fourth grades (University of South Carolina). 

Preventive Intervention Research Center (PIRC) Pro- 
gram. Multidisciplinary PIRCs conduct research of early pre- 
ventive interventions, refine the identification of risk factors 
and experimental epidemiology, and advance prevention re- 
search methodology. PIRCs also support research in clinical, 
academic, and community settings. Each PIRC must provide 
supervised work experiences for a minimum of two trainees 
each year from mental health and related fields. NIMH cur- 
rently funds five PIRCs, which focus on the prevention of (1) 
early risk behaviors in children (Johns Hopkins University), 
(2) mental disorder and behavior dysfunction in chronically 
and seriously ill children (.Albert Einstein College of Medi- 
cine), (3) mental disorder in children experiencing stressful lite 
events (Arizona State University), (4) mental disorder related 
to unemployment stress (University of Michigan), and (5) 
conduct disorder and other disruptive behaviors in school-age 
children (Oregon Social Learning Center). 

Youth Suicide. Suicide is the third leading cause of death 
among people between the ages of 15 and 24. The Secretary's 
Task Force on Youth Suicide, charged with investigating ways 
to prevent youth suicide, developed comprehensive recom- 
mendations that address the need for research, education, and 
services. In accordance with these recommendations, NIMH 
has expanded its role in suicide-related research, coordinated 
by a multidivision suicide consortium. NTMH has also in- 
creased intramural and extramural research efforts and issued a 
program announcement requesting grant applications in sui- 
cide research. Finally, NIMH initiated a youth suicide research 
demonstration grant program at the end of fiscal year 1990. 
Three awards were issued to programs targeting high-risk in- 
dividuals with multifaceted, intensive training interventions re- 
lated to coping skills. The first is a short-term outpatient treat- 
ment program for high-risk young military personnel that 
included psychoeducational, problem-solving, and mood man- 
agement components (Texas A&M University). The second is 
a group problem -solving or support intervention for college 
students who have chronic suicidal thoughts and may have 
made previous suicide attempts (Virginia Polytechnic Institute 
and State University). The third is a year-long personal growth 
class that integrates teacher and peer support aimed at develop- 
ing the life skills and social networks of high-risk high school 
students with a history of substance abuse (University of 
Washington). Other NIMH suicide consortium activities in- 



clude technical assistance to potential grant applicants, re- 
search workshops, an interactive videodisk for medical stu- 
dents, and public information materials. 

Perpetrators of Violence and Victims of Traumatic 
Stress. The past two decades have brought increasing aware- 
ness of interpersonal violence and its mental health conse- 
quences, particularly in the domestic violence and sexual as- 
sault. NIMH has responded to this serious public health 
problem by issuing two program announcements, one inviting 
research on perpetrators of violence (PA-91), the other invit- 
ing research on victims of traumatic stress (PA-92-02). In- 
cluded are specific calls to test and refine models of preven- 
tion, to treat and manage violent behaviors, as well as to study 
social support systems and coping mechanisms and their effect 
on psychological response to traumatic events and stress 
among victims and among human service personnel. The need 
for studies of short-term crisis intervention and long-term 
mental health treatment for victims of all ages and/or their 
significant other and for studies of community programs to re- 
duce or ameliorate emotional trauma and long-term conse- 
quences of traumatic events, is highlighted. In addition, an In- 
stitute-wide violence consortium of has been established to 
coordinate and advance research activities in these areas. 

Special Issues in the Promotion of Minority Mental 
Health and Prevention of Minority Mental Disorders: 
Rural Populations, Ethnic Populations, and Women. In 

1990 the National Advisory Mental Health Council and the 
National Mental Health Leadership Forum jointly sponsored a 
public hearing on mental disorders in rural areas. The NIMH 
program announcement on Research on Mental Disorders in 
Rural Populations (PA-91-52) called for the development of 
primary care and other services to provide basic mental health 
care in remote areas and the study of the effectiveness of pre- 
ventive interventions aimed at modifying known risk factors 
and enhancing psychological functioning. 

NIMH has issued two program announcements regarding 
mental health in ethnic populations. Minority Mental Health 
Research Centers (PA92-122) are being funded to provide re- 
search environments in which state-of-the-art research 
methodologies will be applied to the understanding and im- 
provement of mental health and to the prevention and treat- 
ment of mental illness for American Indians, Alaska Natives, 
Native Hawaiians/Pacific Islanders, African Americans, His- 
panics, or Asian Americans. An additional effort is addressing 
epidemiology, prevention, family, and individual coping 
styles and resiliency, family violence, and service use, treat- 
ment, and quality of care by means of multiple research and 
research demonstration mechanisms (American Indian, 
Alaska Native and Native Hawaiian Mental Health Research, 
PA93-53). 1 

In Social and Behavioral Aspects of Women's Health Over 
the Lifecourse (PA-92-105), NIMH, the National Institute on 
Aging and the National Institute of Child Health and Human 
Development jointly encouraged indepth examination of vari- 



'This announcement is intended to broaden the range of research ini- 
tially stimulated in 1990 by a joint NIMH, NIAAA, and NIDA an- 
nouncement, Epidemiologic and Services Research on Mental Dis- 
orders that Co-occur with Drug and/or Alcohol Disorders Among 
American Indians, .Alaska Natives, and Native Hawaiians. 



m^ 



Prevention '93/'94: Federal Programs and Progress 



ous aspects of women's health and aging: improved life ex- 
pectancy, psychological adjustment and quality of life; 
women's health behaviors, especially in the context of family, 
work, and community; labor force participation over the life 
span and its relationship to women's well-being, health, and 
mortality; multiple roles, stress, stress buffers (such as social 
support), and physical, psychological, and social conse- 
quences; minorities, specific populations and cross-national 
research. The NIMH expressed particular interest in factors 
that contribute to mental health and adaptation, including 
studies of gender differences in contributing psychological 
processes and studies of interpersonal, family, societal, and 
cultural processes that affect mental health outcomes. Special 
Issues in Women's Mental Health Over the Life Cycle (PA- 
91-100) addresses mood, behavioral, cognitive and somatic 
changes associated with menstrual- and reproductive-related 
neuroendocrine fluctuations in women. Attention is directed 
to the etiology, treatment, and prevention of mental illness, 
including premenstrual syndrome/late luteal phase dysphoric 
disorder; reproductive changes associated with mood and be- 
havioral changes and disorders; mental health effects of psy- 
chosocial issues in the timing/control of reproduction; preg- 
nancy-related and postpartum mental disorders; psychological 
and physical conditions associated with the decrease and sub- 
sequent cessation of significant ovarian steroid production at 
menopause and during the post-menopausal period; and gen- 
der differences in the predisposition to mental disorders, such 
as the heightened risk of women for eating disorders, panic 
disorder, depression, and seasonal affective disorder and their 
lower risk for alcoholism and sociopathy. 



National Institute of 
Neurological Disorders and 
Stroke (ninds) 

The National Institute of Neurological Disorders and 
Stroke (NINDS) conducts and supports research on the 
causes, diagnosis, treatment and prevention of neurological, 
neuromuscular, and cerebrovascular disorders. NINDS pro- 
vides funding for basic and clinical neurological research and 
for institutional and individual training fellowships to 
encourage future scientific leadership in the neurological 
sciences. 

A public law enacted in 1989 designated the 1990s as the 
Decade of the Brain. An implementation plan was prepared bv 
the National Advisory Council of the NINDS, and recently 
Progress and Promise: Status Report on the Decade of the Bruin re- 
viewed the progress that has been made in basic and clinical 
research on neurological disorders and the major areas of op- 
portunity for further advancement. 

NINDS Prevention Highlights 

Prevention Through Genetic Research. The central ner- 
vous system is uniquely susceptible to developmental, trau- 
matic, and degenerative disease. One of the most promising 
areas "I research concerns the prevention of neurogenetic .un\ 
neurodevelopmental disorders. At least 25 percent of the 
4,000 known genetic disorders affect the nervous system di- 
rectly; many more have ancillary effects. 



Researchers at the NINDS laboratories have shown that 
enzyme replacement therapy is beneficial in preventing the 
lite-threatening symptoms in patients with a lipid-storage dis- 
order called Gaucher's disease, a therapy that may be feasible 
in other neurologic disorders. Gene therapy, a technique de- 
signed to replace or augment the patient's own detective 
genes, is being explored for preventing some neurological dis- 
orders. 

Some genetic disorders manifest symptoms overtly, as in 
Huntington's disease, but others are influenced by genes in 
more subtle ways. Epilepsy, multiple sclerosis, and even stroke 
are now known to be influenced by genetic factors. Alzheimer's 
disease and Parkinson's disease are influenced by a complex in- 
teraction of genetic and environmental factors. NTNDS con- 
tinues to support basic research to elucidate these factors. 

Prevention of Infant Mortality and Developmental Disor- 
ders. NINDS is supporting a major clinical trial to examine 
methods for preventing intracranial hemorrhage in neonates. 
Other research is focusing on the prevention of some common 
birth defects such as spina bifida, a malformation of the neural 
tube that occurs in the first month of fetal development. Re- 
cent studies have shown that adequate maternal intake of folic 
acid at conception diminishes the risk of neural tube defects. 
Fundamental studies of genetic and developmental factors 
offer promising approaches to the prevention and treatment 
of many other conditions leading to infant mortality. 

Prevention of Epilepsy. Traumatic brain injury- — both the 
immediate trauma and the secondary injury that follows it — is 
responsible for 5,000 new cases of epilepsy each year. A reduc- 
tion in head injuries through such public health efforts as seat- 
belt and helmet use would obviously do much to reduce the 
incidence ot epilepsy. NINDS is actively testing anti-epileptic 
drugs to evaluate their potential for preventing the develop- 
ment of new cases of epilepsy in victims of head injury. Addi- 
tionally, it is pursuing the question of prevention of secondary 
injury following head trauma. 

NINDS scientists have begun exploring the possibility of 
developing a vaccine icr a parasitic disease neurocvsticercosis, 
a common cause of epilepsy worldwide. Y\fiile not highly 
prevalent in this country, it is found in some immigrant popu- 
lations. In the United States, prevention of meningitis and en- 
cephalitis would also prevent many cases of epilepsy. 

While antiepileptic drugs are well accepted as treatment tor 
epilepsy, little is known about their role in preventing or de- 
laving its progress, or their long-term effects. These issues will 
be addressed in future studies. 

Stroke Prevention. Recent findings from a stud) supported 
by NINDS concluded that stroke risk could be cut b) 50 to 80 
percent in individuals with atrial fibrillation by treating them 
with aspirin or an anticlotting agent called warfarin. Employ- 
ing this treatment could prevent about 20,00(1 to $0,000 
strokes a year. Another multicenter trial is now underwa) to 
test the safety and efficacy of synthetic heparinoid in halting 
the growth ol existing clots and preventing new ones. 

A partially blocked carotid artery in the neck is often con- 
sidered an indicator of poor circulation to the brain. NINDS 
grantees have reported that carotid endarterectomy, a proce- 
dure to surgically remove these blockages, is highly effective 
in preventing stroke in persons who have severe blockage. 



{ ff) 



Agency Innovations 



The study is continuing, now focusing on its efficacy for those 
who have a moderately narrowed artery. 

In order to find out why African Americans have one of the 
highest stroke rates in the world, the NINDS has initiated two 
5 -year studies to identify risk factors for stroke in this popula- 
tion and specific prevention strategies. 



National Institute of Nursing 
Research (ninr) 

The National Institute for Nursing Research conducts and 
supports basic and clinical research and research training to 
build the scientific base for nursing practice. NINR Health 
Promotion and Disease Prevention Program places special 
emphasis on behavioral, physiological, and environmental fac- 
tors that prevent disease and promote health across the life 
span. NINR places special emphasis on populations at greatest 
risk for illness and disability, such as minority and ethnic 
groups, women, older people, and disabled persons. Studies of 
preventable health problems in the emerging lifestyles of chil- 
dren and adolescents are also encouraged. 



NINR Prevention Highlights 

Low Birth Weight. Low birth weight (less than 5 pounds) is 
associated with large numbers of infant deaths each year in the 
Lmited States. Low-birth-weight infants are 40 times more 
likely to die during their first month of life than those born at 
normal weight and 2 to 3 times more likely to suffer from 
chronic handicapping conditions, such as blindness, mental 
retardation, and deafness. The care provided in neonatal in- 
tensive care units is critical to their survival and healthy devel- 
opment. The extreme fragility of these infants, especially the 
very-low-birth-weight babies (3 pounds or less), requires spe- 
cial nursing practices for handling, feeding, respiratory care, 
and skin care. In response to these needs, NINR supports 
studies concerning the special care requirements of low-birth- 
weight infants. 

One area under investigation concerns individual differ- 
ences in sucking behavior among infants. Characterization of 
this behavior may permit early identification of impaired in- 
fants and assessment of their neurological development and 
ability to adjust to their environment. An NINR grantee has 
already demonstrated that tracings of sucking patterns illus- 
trate the organizational differences between pre-term and full- 
term infants. The full-term infant generates more sucks per 
burst with greater pressures over a longer period of time. In- 
formation on infant sucking patterns will lead to the develop- 
ment of a clinical tool to assess neurobehavioral maturation in 
the neonatal period, identify impaired infants, and measure 
outcomes of interventions. 

Another investigator is relating patterns of sleep-wake states 
and associated activity patterns, respiration, and vocalizations 
observed during the pre-term period to developmental status, 
such as social competence, cognitive ability, health status, lan- 
guage skills, motor abilities, and sleep patterns, at age 3. 

Children and Adolescents. Many of the most important risk 
factors for chronic disease in later years have their roots in 
health-compromising behaviors that begin in childhood and 



adolescence. Attitudes and habits related to diet, physical ac- 
tivity, alcohol abuse, tobacco use, and sexual behavior often 
persist from adolescence into adulthood. 

NINR supports three exploratory centers to investigate 
health-risk behaviors, strategies for their prevention, and pro- 
motion of healthy behaviors in adolescents. These centers, lo- 
cated at the University of Kentucky, the University of Texas 
Health Science Center, and the University of Michigan, have 
undertaken pilot studies on tobacco and alcohol use, the effect 
of zinc deficiency on teen pregnancy, diet and exercise modu- 
lation, oral health, and sexual activity. Study populations are 
drawn from diverse racial and socioeconomic backgrounds. 
The center in Kentucky is concerned with young people in 
rural settings. 

The health of children aged 8 to 18 is being addressed in a 
new initiative to design community-based interventions that 
foster health-promoting cognitive and behavioral patterns in 
this age group. Specific objectives include the development of 
(1) family, school, and community strategies for adopting and 
maintaining health-promoting behaviors among young people 
in traditional health-care settings such as emergency facilities, 
school-based clinics, and medical offices; and (2) alternative 
health-promotion models and outreach strategies in urban 
and rural settings such as youth-serving community agencies, 
shelters for runaways and the homeless, malls, churches, and 
youth-employing worksites. Highly vulnerable groups are of 
special concern and include members of minority subgroups, 
immigrants, and economically disadvantaged, homeless, and 
disabled individuals. 

Prenatal Care and Health in Pregnancy. An important fac- 
tor in pregnancy outcomes is the mother's support system. A 
number of support interventions are being designed and 
tested by NINR grantees to determine their effects on mater- 
nal health and behaviors, on birth weight and other pregnancy 
outcomes, and on recovery from pregnancy and delivery. 

Because many women at risk for pregnancy complications 
and pre-term labor are members of minority groups and often 
live in rural areas, two key aspects of effective interventions 
are their cultural sensitivity and their accessibility to rural 
women. Nursing practice models that provide prenatal and 
post-partum support are currently being developed and tested 
for women in low-income African American communities, for 
Hawaiian, Filipino, and Japanese women in rural Hawaii, and 
for Native American and Hispanic women in rural Oregon. 

Preliminary findings are available from the study of low-in- 
come African American women. In this study, routine prenatal 
care was augmented with regular telephone contact by perina- 
tal clinical nurse specialists who assess for and heighten aware- 
ness to early warning signs of premature labor, thereby per- 
mitting timely interventions to reduce the number of early 
deliveries. Of the women in the intervention group, 6.7 per- 
cent delivered low-birth-weight infants, while 1 1.9 percent of 
the women who received routine prenatal care delivered low- 
birth-weight infants. These results suggest that this type of in- 
tervention is a potentially low-cost method of reducing low- 
birth-weight outcomes. 

Another approach, characterized by home visitations by 
nurses to expectant and new mothers, is being evaluated. 
Nurses assume educational, counseling, and nurturing roles in 
a nurse home-visitation program for poor, unwed pregnant 
women bearing their first babies. The purpose of the study is 



^fe 



Prevention '93/'94: Federal Programs and Progress 



m 



to determine whether the home-visitation program improves 
prenatal health habits, infant caregiving skills, and mental 
health functioning; encourages the use of community services 
and educational and occupational achievements; and helps re- 
duce unwanted additional pregnancies. 

Interventions that address other dimensions of childbearing 
are also being developed with NLNR support. A nursing role 
supplementation program is being developed for first-time 
adolescent mothers between the ages of 14 and 18. The goal 
of the program is to promote effective maternal behaviors by 
providing role modeling, role rehearsal, information-sharing, 
and support and counseling. 

National efforts to control health care costs have resulted in 
the development of alternative methods of care delivery. One 
such alternative is transitional home follow-up care. This 
model of care is designed to discharge patients early from the 
hospital by substituting a portion of hospital care with a com- 
prehensive program of home follow-up by nurse specialists. 
The clinical nurse specialists prepare patients for early dis- 
charge, conduct scheduled home visits, and are available by 
telephone 24 hours a day with backup support from the pa- 
tient's physician. 

The effects of transitional home follow-up care were also 
studied in a group of childbearing women with diabetes and 
their infants. Low birth weight was 3 times more prevalent in 
the control group than in the group of infants whose mothers 
received the intervention early in their pregnancies. IVlore- 
over, researchers found that the women who received the in- 
tervention were discharged earlier, had fewer re-hospitaliza- 
tions, and had a 38-percent reduction in health care costs 
compared to the control group. 

Transitional home follow-up care was also compared with 
routine hospital care in a group of women delivering by un- 
planned cesarean birth. Findings indicate that the women who 
received the intervention were discharged an average of 30 
hours earlier and reported greater satisfaction with their care. 
The intervention resulted in an average reduction of 29 per- 
cent in health-care costs as compared to routine hospital care. 

Women's Health at Midlife. More attention must be paid to 
health issues at midlife, especiallv for women. Menopausal 
symptoms, sleep disturbances, changes in gut function, and 
the stress of multiple roles resulting from careers and respon- 
sibilities for both children and aging parents — all require in- 
tensive research to improve health and well-being in this age 
group. 

Hormonal changes that precipitate disease conditions are 
responsible for loss of functional ability in many midlife 
women. Studies are being carried out to determine the physio- 
logical basis for such conditions and to develop interventions 
that alleviate suffering and disability. Topics under investiga- 
tion include symptoms related to menstruation, complications 
ol hormonal imbalance, sleep disturbances in menopause, de- 
cisions regarding estrogen replacement therapy, and correla- 
tion between physical activity and bone mineral density. 

( )ne interesting study focuses on ovarian hormone modula- 
tion of gastrointestinal function. Perimenopausal ami post- 
menopausal women frequent]} experience constipation :\m\ 
abdominal pain and distension. These symptoms are consis- 
tent with slowed gastrointestinal motility. While it is known 
that ovarian hormones modulate gut motility, the effects ol 
fluctuating ovarian hormone levels on gastrointestinal func- 



tion during perimenopause and post-menopause remain 
unclear. 

Nurse investigators have been examining the influence of 
ovarian hormones on gastrointestinal structure and function 
in a rat model. Levels of estrogen and progesterone are ma- 
nipulated in ovariectomized rats in order to examine the ef- 
fects of hormone replacement and dietary fiber supplementa- 
tion on gut motility. The investigators have found that gut 
motility in ovariectomized rats treated with progesterone was 
37-percent slower than in rats treated with estrogen or estro- 
gen plus progesterone. In addition, estrogen treatment was 
shown to increase gut muscle tension. The administration of 
dietary fiber to ovariectomized rats receiving no hormone re- 
placement was associated with a 60-percent increase in gut 
transit. These findings indicate that estrogen replacement and 
dietary fiber supplementation may help to alleviate the ab- 
dominal discomfort often experienced by menopausal women. 

NLNR is also funding a specialized Center for Women's 
Health Research that focuses on midlife health issues includ- 
ing the health and health-seeking behaviors of a diverse cohort 
of midlife women; nonspecific physical symptoms and stress 
responsivity; and circadian temperature rhythms and sleep. In 
one substudy, more than 450 women aged 35 to 55, including 
ethnic minorities and those with low-income lifestyles, are 
being tracked over a 3-year period to examine the demands 
made upon them and their resources, the multiple roles they 
must fill, and the relationship of these factors to illness. 

Screening and Early Detection. Early detection of disease 
can be a key deterrent to serious, long-term illness. Factors 
that influence an individual's decisions about early detection 
procedures require more research. For example, regular self- 
examination allows many breast cancers to be discovered at a 
more clinically favorable stage. Women who are at greatest 
risk for developing breast cancer and who are least likely to 
complete a monthly breast self-examination are those age 35 
and over. In an NLNR-supported study, attitudes toward 
breast cancer, self-examination practices, and mammographv 
are being investigated among women in this age group. Find- 
ings from this study will be used to develop nursing interven- 
tions to increase breast examination in women 35 and over. 

A community-based nursing intervention to increase col- 
orectal cancer screening has been tested in a group of socioeco- 
nomicallv disadvantaged, poorly educated white and African 
American older adults. Traditionally, when these individuals 
aic given stool kits to detect colorectal cancer, they often do 
not return them because they are unable to read or understand 
the directions. Nurse researchers have found, however, that 
when peers were used as role models to explain and demon- 
strate the us!.- of the kits, the rate of returned kits increased sig- 
nificantly. All average of SS percent of the intervention group 
returned their tests, while only 52 percent of the tests were re- 
turned by the control group. 'This stud} demonstrates an effec- 
tive, community-based cancer-screening program developed 
specifically for sociocconomically disadvantaged people. 

Another nurse investigator has assessed the effectiveness ol 
a community-based nursing intervention in reducing the 
prevalence ol cardiovascular risk factors in a group ot S- to 10- 
\ ear-old children living in a rural community. The investiga- 
tor found that these children had higher blood pressures, 
higher total cholesterol levels, and higher measurements of 
body fat than urban children ol the same age. After the inves- 



Agency Innovations 



tigators introduced a nurse-designed educational program 
taught by classroom teachers, the cholesterol levels of the chil- 
dren who participated in the program showed an average drop 
of 7.9 mg/dl while those who did not participate showed an 
average rise of 3.5 mg/dl. 



National Library of Medicine (nlm) 



NLM Prevention Highlights 

Outreach to Maternal and Child Health Care Providers in 
the Lower Mississippi Delta. The NLM outreach program is 
a cooperative effort with the 3,600 member institutions of the 
National Network of Libraries of Medicine. NLM has initi- 
ated more than 200 outreach projects, involving nearly 400 in- 
stitutions, since the publication of the DeBakey report in 1989. 
They include extensive efforts to train physicians and other 
health professionals to use Grateful Med, through projects at 
the Regional Medical Libraries and awards to small-to- 
medium sized network libraries to improve both local re- 
sources and access to online information. There is a special 
emphasis on rural and inner-city areas and minority popula- 
tions. There is also a special initiative in the Toxicology Infor- 
mation Program to strengthen the capacity of nine Historically 
Black Colleges and Universities to train medical and other 
health professionals in the use of toxicological, environmental, 
occupational, and hazardous waste data bases at NLM. 

Planning for an expanded outreach effort in the Lower Mis- 
sissippi Delta began in late 1992 and is being carried out with 
the assistance of the Southern Institute on Children and Fam- 
ilies. In the coming months, meetings to establish linkages 
with key governmental, health, academic and local community 
organizations will be held in six Southern States. This out- 
reach approach seeks to identify health-related activities fo- 
cused on the health of pregnant women and children. 

MEDLARS. The National Library of Medicine (NLM) collects 
materials exhaustively in all major areas of the health sciences. 
The Library's computer-based Medical Literature Analysis and 
Retrieval System (MEDLARS) was established to achieve rapid 
bibliographic access to this vast store of biomedical information. 
MEDLARS contains some 40 data bases, of which the MED- 
LINE data base is the best known. Many of these provide health 
promotion and disease prevention information; others provide 
comprehensive information on cancer and MDS research. 
NLM provides worldwide access via MEDLARS. 

DIRLINE. NLM's Directory of Information Resources On- 
line (DIRLINE), an online interactive data base about organi- 
zations which will respond to public inquiries, provides refer- 
rals to organizations involved in disease prevention and health 
promotion. DIRLINE also provides access, via MEDLARS, 
to the Self-Help Clearinghouses (SHC) data base produced 
through collaboration with the Surgeon General's Initiative in 
Self-Help and Public Health and the National Health Infor- 
mation Center data base produced by the DHHS Office of 
Disease Prevention and Health Promotion. 

Full-Text Databases. NLM has created an experimental full- 
text online retrieval system. For prototype development, 



NLM is using the Guide to Clinical Preventive Services: An As- 
sessment of the Effectiveness of 169 Interventions, a report of the 
U.S. Preventive Services Task Force published in 1989, and a 
file comprised of some 89 NIH Consensus Development 
Conference Reports. This research and development effort 
will create a prototype of a full-text data base, which will in- 
clude the Agency for Health Care Policy and Research clinical 
practice guidelines. 

Teenage Suicide Prevention. NLM and the National Insti- 
tute ot Mental Health have developed an innovative com- 
puter-controlled videodisk curriculum, "The Suicidal Adoles- 
cent: Identification, Risk Assessment, and Intervention." 
Designed for medical students, the interactive videodisk pro- 
gram helps raise awareness levels concerning the hidden signs 
of an impending suicide and what to do about it. The program 
includes a series of simulations of depressed adolescents and 
are used to explore physicians' attitudes and to highlight inter- 
view skills, decision making in gathering information, assess- 
ment of suicide risks, and appropriate intervention. 

Cervical Cancer: Success in Sight. This videodisk serves as 
an electronic journal allowing the user to randomly access a 
range of topics related to cervical cancer. Program topics in- 
clude incidence and mortality data, risk factors, and the 
screening process. The program utilizes a visual data base of 
cytology slides to identify "adequate" and "inadequate" smears 
and histology and cytology slides to identify abnormalities. 
"Viewpoint" is a user query section in which questions related 
to three key screening topics are presented. The user then has 
the opportunity to select video responses from four experts in 
the field. The program was first developed as an interactive 
videodisk and soon will be available from the National Cancer 
Institute in a Compact Disc — Interactive (CD-I) format. 

Clinical Alerts. NTH has instituted a clinical alert system 
whereby the medical community is notified ot major results of 
clinical trials prior to formal publication. Once an NTH Insti- 
tute director has determined that expedited release of findings 
from a clinical trial could affect morbidity and mortality, NIH 
uses the National Library of Medicine's online services and 
the National Network of Libraries of Aledicine to announce 
findings. On January 18, 1991, NLAT disseminated the first 
clinical alert over its MEDLARS Network. To date, nine 
alerts have been distributed. 

Toxicology and Environmental Health. Hazards to the 
public health and the environment from chemicals are the re- 
sult of advancing industrialization, changes in agricultural 
practices, and improper storage, handling, transportation, and 
disposal. Of particular importance are the effects of chemicals 
to which people may be exposed at low concentrations over 
prolonged periods, because in these cases the toxic effects may 
be subtle and difficult to discern. The chemical and toxicolog- 
ical data bases of NLM provide data and information about 
exposures to chemical, physical, or biological agents that are 
of particular importance in the prevention of occupational and 
environmental illnesses. 

AIDS Bibliography. The AIDS Bibliography is a monthly 
NLM-produced bibliography that contains citations to jour- 
nal articles, monographs, international conferences and audio- 



® 



Prevention '93/'94: Federal Programs and Progress 



visuals on all preclinical, clinical, epidemiologic, diagnostic, 
therapeutic, and prevention areas of HIV or AIDS added to 
NLM's MEDLINE, Health Planning and Administration, 
CANCERLIT, CATLINE, and AVLINE data bases. 

Current Bibliographies in Medicine. NLM also produces 
Current Bibliographies in Medicine (CBM), a series that covers a 
wide variety of topics, including health promotion, disease 
prevention, and women's health issues. Each bibliography in 
the series covers a distinct subject area of biomedicine and ci- 
tations are usually derived from a variety of online data bases. 
Some recent CBMs are entitled Seafood Safety, Silicone Im- 
plants, Adolescent Alcoholism, Electromagnetic Fields, Gallstones 
and Laparoscopic Cholecystectomy, Methods for Voluntary Weight 
Loss and Control, Seasonal Affective Disorder, Triglyceride, High 
Density Lipoprotein and Coronary Heat Disease, and Disease Pre- 
vention Research. 

Prevention Posters. Posters persuade the public to stop 
smoking, eat well, and practice safe sex, among other things. 
The use of this form of public communication plays an impor- 
tant role in the arena of health promotion and disease preven- 
tion. The NLM has archived a collection of more than 4,500 
posters. Selections of posters are exhibited at the NLM peri- 
odically and are shown in a succession of science museums and 
libraries around the Nation. 



Warren Grant Magnuson 
Clinical Center (cc) 

The Warren Grant Magnuson Clinical Center is the re- 
search hospital unit of NIH and thus is the Federal Govern- 
ment's primary clinical facility for biomedical investigation. 
The CC provides and supports approximately 500 patient 
beds, 50 clinics, and 2,000 laboratories to enhance the NIH 
clinical research mission. 

CC Prevention Highlights 

Occupational Bloodborne Infections. Occupational expo- 
sure to human blood and other body fluids is the major risk for 
health care workers to acquire bloodborne infections such as 
hepatitis and HIV. Public Health Service recommendations, 
frequently referred to as Universal Precautions, are designed to 
minimize health care worker exposures to potentially infec- 
tious materials (primarily human blood and other body sub- 
stances). Studies of health care workers at CC are being pur- 
sued to determine the efficacy of Universal Precautions in 
preventing occupational exposures to potentially infectious 
materials. The study findings support the important role of 
Universal Precautions in decreasing occupational exposures. 

Measles Immunity of Health care Workers. With the re- 
cent resurgence ol measles and measles outbreaks in the 
health care setting, national vaccination guidelines encourage 
health care institutions to develop programs to ensure that 
employees are immune to measles. A.CC Stud) is in\ estigating 
the seroepidemiology ol measles anil immune response to 
measles vaccine in a population of newly employed health care 
\\"il. rrs. findings suggest ihal employees born outside the 



L'nited States are more likely to be immune than those born in 
the United States. The recommended birthdate cutoff of 1957 
(assuming everyone born before 1957 is immune to measles) 
misses some susceptible persons and could be improved by 
lowering the cutoff birthdate to 1951. Furthermore, follow-up 
of adult vaccine recipients identified some with suboptimal 
antibody responses, which may include a subpopulation of 
hypo-responders. These findings may provide new direction 
for health care institutions to design effective and economical 
programs to prevent measles transmission in the health care 
setting. 

Safety of Zidovudine. Zidovudine (AZT) has been shown to 
delay the progression of disease in persons infected with HIV. 
Health care workers who experience occupational exposures 
to HIV, such as cuts or punctures with contaminated sharp 
objects, have a small but measurable risk of acquiring HIV in- 
fection. Little is known about the effectiveness of AZT in pre- 
venting HIV infections in health care workers following occu- 
pational exposures to HIV or its toxicity in this setting. The 
CC and the University of California San Francisco/San Fran- 
cisco General Hospital are conducting a collaborative multi- 
center open-label study to address these issues. The aims of 
the study are to evaluate the toxicity of AZT when adminis- 
tered as a short course to health care workers following occu- 
pational exposure to HIV and to describe the epidemiology of 
exposures to HIV for which AZT chemoprophylaxis is 
elected. Preliminary findings indicate that over a third of the 
participants discontinued .AZT prophylaxis because of subjec- 
tive toxicities or personal reasons, although no participants 
had documented objective toxicities, based on physical or lab- 
oratory findings. No HIV infections have been detected, but 
the study population is small, and none would be anticipated. 
These data indicate that zidovudine can be safety administered 
as post-exposure prophylaxis to health care workers following 
occupational exposures to HIV. 



Substance Abuse 
and Mental Health 
Services 
Administration 
(samhsa) 



The Substance Abuse and Mental Health Services Adminis- 
tration has lead responsibility for the Federal Government's 
support mm\ conduct ol programs and initiatives to ensure that 
knowledge, based on science and sl.ile-ol-the-art-practice. is 
effectively used for the prevention and treatment of addictive 
and mental disorders. S Wll IS \ also stn\ es t<> improve access 
and reduce barriers to high quality, effective programs and 
sen ices lor individuals who either surfer from or arc at risk for 
these disorders, as well as tor their families and communities. 
I nder this mandate, S Wll IS \ designs and promotes innova- 



Agency Innovations 



rive public health service demonstration programs to treat 
these disorders and to prevent related consequences such as 
HIV/AIDS and violence. SAMHSA's mission is accomplished 
through the Center for Mental Health Services, the Center 
for Substance Abuse Prevention, and the Center for Substance 
Abuse Treatment. (Effective October 1, 1992, SAVIHSA was 
created as a result of the Alcohol, Drug Abuse, and Mental 
Health Administration (ADAMHA) Reorganization Act.) 



Center for Mental Health 
Services (cmhs) 

With its Congressionally mandated prevention mission, the 
Center for Mental Health Service develops and coordinates 
Federal prevention policies and programs to ensure increased 
focus on the prevention of mental health disorders and the 
promotion of mental health. 

During the last 10 years, major advances in the develop- 
ment of preventive interventions have been made, particularly 
for mental disorders among children and adolescents, suicide 
attempts among adolescents and adults, and the negative im- 
pacts of stress among adults. Translation and application of 
these advances into well-evaluated and practical mental health 
service delivery programs capable of intervening and mediat- 
ing are needed. 

CMHS Prevention Highlights 

Workgroup on Operating Definitions. CMHS is developing 
working definitions of prevention through a working group 
representing an array of mental health services. The workgroup 
met in early 1993 to make recommendations on program prior- 
ities and strategies in the mental health prevention area. 

Annual Mental Health Prevention Forum. An annual as- 
sembly convened by CMHS brings individuals interested in 
mental health services together for a review and discussion of 
developments during the previous year. Activities in the public 
and private sectors at the national, State, and local levels will 
be highlighted at the forum and the proceedings will be 
published. 

Coordination and Liaison Program. CMHS engages in ex- 
tensive liaison and networking activities to gather information 
about prevention activities. Priority issues to be addressed by 
CiVIHS during 1993 include seriously mentally ill and respite 
care; seriously emotionally disturbed children; and workplace 
stress. 



Center for Substance Abuse 
Prevention (csap) 

The Center for Substance Abuse Prevention was created by 
the Anti-Drug Abuse Act of 1986 to lead the Federal Govern- 
ment's efforts toward prevention of alcohol, tobacco, and 
other drug problems. CSAP also provides Federal leadership 
to stimulate and support partnerships within all sectors of so- 
ciety to create a holistic prevention agenda to foster healthy 



individuals, families, organizations, 
ciallv anions; those most at risk. 



communities, espe- 



CSAP Prevention Highlights 

SAMHSA Policy on Mcohol, Tobacco, and Other Drug 
Abuse. One of CSAP's primary tasks is to promote the policy 
message that there should be no illegal use of alcohol, tobacco, 
or other drugs. Because of the complexity of drug problems, 
innovative prevention approaches must be carefully planned, 
implemented, and evaluated. 

Emphasis on High-Risk Youth and Families. The preven- 
tion of alcohol, tobacco, and other drug use among America's 
youth is supported by a demonstration grant program for pro- 
jects that promulgate models for preventing use by high-risk 
youth. CSAP has funded High-Risk Youth grants since FY 
1987. By the end of FY 1992rCSAP had awarded 314 grants. 
In FY 1993, 152 of these grants continue to be operational, 
and 5 new grants were funded as of December 1992, at a total 
cost of approximately $1.5 million. 

Emphasis on Pregnant and Post-Partum Women and 
their Infants (PPWI). CSAP funds projects that focus on 
prevention, education, and treatment in community, inpa- 
tient, outpatient, and residential settings for pregnant and 
post-partum women and their infants. These projects demon- 
strate promising models to prevent or minimize fetal exposure 
to alcohol, tobacco, and other drugs, improve birth outcomes, 
reduce functional impairment, and strengthen or expand ser- 
vice delivery of therapeutic programs, comprehensive sup- 
portive services, and medical care. With about $47.6 million 
in 1993, 134 programs are planned for low-income women at 
high risk under the PPWI initiative. 

Community Partnership Demonstration Grants. CSAP has 
developed and is implementing comprehensive, long-term 
community alcohol, tobacco, and other drug abuse preven- 
tion/intervention strategies, programs, and service support ac- 
tivities through community-wide coalitions and partnerships. In 
FY 1993, emphasis is on the implementation of drug prevention 
programs in the workplace. CSAP anticipates supporting 244 
communities under the Community Partnership Program with 
$95 million in FY 1993. Many of these partnerships are targeted 
towards communities having significant minority populations, 
including a binational U.S. -Mexico Border initiative. 

Cooperative Agreements for Communication Projects. 

CSAP supports communication programs that will help pre- 
vent alcohol, tobacco, and other drug problems in high-risk 
audiences and their environments. CSAP promotes efforts 
that carefully develop, test, disseminate, and evaluate public 
information and community health education projects by in- 
volving the target audience. In FY 1993, CSAP supported 
three cooperative agreements under this program. CSAP also 
has funded a specialized data base and information center. In 
FY 1993, CSAP will support three cooperative agreements 
under this program. 

Community-Based Research on the Prevention of Alco- 
hol-Related Problems. CSAP and the National Institute on 
Alcohol Abuse and Alcoholism (NIAAA) sponsor research in 



ffh 



Prevention '93/'94: Federal Programs and Progress 



^^ 



community-based intervention trials for the prevention of al- 
cohol-related problems among high-risk youth groups, young 
adults, and minority populations. The community-based re- 
search program emphasizes intervention using the public- 
health model. 

CSAP's National Clearinghouse for Alcohol and Drug In- 
formation (NCADI). The clearinghouse is a major Federal 
resource of current print and audiovisual information on alco- 
hol, tobacco and other drugs. CSAP's Regional Alcohol and 
Drug Awareness Resource (RADAR) Network works in part- 
nership with NCADI and consists of State clearinghouses, 
specialized information centers of national organizations, the 
Department of Education Regional Training Centers, and 
others. They help distribute information, conduct media cam- 
paigns, and obtain feedback for improving communication 
sendees and products. 

Message and Materials Review and Development. CSAP 

is engaged in the review and evaluation of the plethora of alco- 
hol, tobacco, and drug messages and materials that have been 
developed by both the public and the private sectors. Review- 
ers assess the accuracy, consistency, utility, and appeal of cur- 
rent messages and materials and identify areas where new ma- 
terials need to be developed. As appropriate, CSAP generates 
new messages and materials, especially for hard-to-reach and 
high-risk audiences. 

PreventionWORKS! Campaign. CSAP is launching a major 
new campaign to inform the public how much prevention of 
alcohol, tobacco, and other drug problems saves in terms of 
lives, productivity, and overall health care costs. Materials and 
technical assistance are available through NCADI and the 
RADAR Network. 

The National Prevention Training System. The National 
Prevention Training System consists of Curriculum Develop- 
ment and Training — to develop and pilot test curricula for 
health care professionals; Community Prevention Training — 
to provide specialized training to community partnership 
grantees and other communities that have established coali- 
tions; Medical Education — for health professionals; and Na- 
tional Volunteer Training for Substance Abuse — training for 
volunteers in prevention activities. The total appropriation for 
FY 1993 is $14.5 million. 

Workplace Programs. These programs set standards for drug 
testing in workplace settings. The budget for contracts to sup- 
port this effort has been established at $1.1 million for FY 1993. 
The Employee Assistance Program (EAP) will provide assis- 
tance to public and private nonprofit employers who cannot af- 
ford to establish and operate EAPs without Federal assistance. 
Funds were not appropriated for this program in FY 1993. 

State Liaison Program. I Ins program is designed to support 
alcohol, tobacco, and other drug abuse prevention efforts in 
the States. This objective is pursued through three groups ol 
activities, first, CSAP works with the States to enhance their 
development and support of activities funded by the Substance 
Abuse Block Cram. Second, CSAP supports methodological 
development ol tools necessary to improve the prevention ser- 
vices in the States, such as needs assessment, program evalua- 



tion, and development of practice guidelines called Prevention 
Enhancement Protocols. Finally, CSAP coordinates its vari- 
ous programs of technical assistance to States and capacity- 
building initiatives with allied professional organizations to 
achieve mutual prevention objectives. 

Field Development. Components of CSAP's field develop- 
ment include the Learning Community, technical assistance 
efforts to community prevention programs, Exemplary Pre- 
vention Program Awards, special prevention Issue Forums, 
an Impaired Driving Initiative, and multichannel Media 
Campaigns such as L'rban Youth Public Education Cam- 
paign, Children of Alcoholics Education Program, Put on the 
Brakes! Take a Look (At College Drinking), and Piensalo! 
Stay Smart! Don't Start! Through its conference grants pro- 
gram, CSAP funded 40 prevention conferences in FY 1993. 

Resource Centers. CSAP operates three national resource 
centers that provides technical assistance in specific program 
areas. They are the National Resource Center for Prevention 
of Perinatal Abuse of Alcohol and Other Drugs, the National 
Volunteer Training Center for Substance Abuse Prevention, 
and the National Prevention Evaluation Resource Center. 

Prevention Pipeline. CSAP's bimonthly newsletter, Preven- 
tion Pipeline, provides information about alcohol, tobacco, and 
other drug prevention efforts to more than 6,500 subscribers. 
Reader exchanges are encouraged. The results of evaluation 
efforts, information about upcoming events and CSAP find- 
ings are reported. 

Linkages and Interagency Cooperation. Since its incep- 
tion in 1986, CSAP has forged linkages with other agencies to 
develop comprehensive approaches for prevention and early 
intervention. CSAP and the Department of Justice have es- 
tablished boys' and girls' clubs in public housing projects. 
CSAP and the National Crime Prevention Council, the Bu- 
reau for Juvenile Assistance, and private publishers produced 
4 million children's coloring books and comic books with an 
antidrug message. CSAP and other Federal clearinghouses 
developed an interagency publications catalog for local and 
State policymakers. CSAP also collaborated with the Depart- 
ments of Education and Transportation on a series ot work- 
shops to help prevent traffic accidents due to alcohol and 
other drus' use. 



Center for Substance Abuse 
Treatment (csat) 

The Center for Substance Abuse Treatment was created in 
October 1992 with the congressional mandate to expand the 
availability of effective treatment and recover) services tor al- 
cohol and other drug problems. 

An estimated 21 million Americans abuse alcohol and other 
drugs. To meet the needs of these individuals and their family 
members, who together number in excess of 75 million, an 
atT.iv of intervention, treatment. .wu\ recover) programs exist 
in thousands of communities across the United States. 

Ii is in this context that CSAT endeavors, in partnership 
with State and local governments ,\\u\ community-based pro- 



Agency Innovations 



grams, to improve the availability and effectiveness of addic- 
tion treatment and recovery services on a nationwide scale. 

CSAT Prevention Highlights 

In support of its vision and mission, CSAT currently ad- 
ministers the following programs. 

Substance Abuse Prevention and Treatment Block Grant. 

CSAT is responsible for administering the Substance Abuse 
Prevention and Treatment (SAPT) block grant, whose total 
FY 1993 funding is authorized at $1.5 billion. These funds are 
allocated to each State according to a formula legislated by 
Congress. States distribute these funds to cities and counties 
based upon need. Funds may be used for the conduct of 
State/local demand and capacity assessments; the development 
of statewide prevention and treatment improvement plans for 
narrowing service gaps, implementing staff training efforts, 
and fostering coordination among substance abuse treatment, 
primary health care, and human service agencies; and address- 
ing human resource requirements, clinical standards, and 
identified treatment improvement goals. 

Capacity Expansion Program. The Capacity Expansion 
Program (CEP) provides resources for the creation of new ad- 
diction treatment capacity in jurisdictions where there is a 
documented gap between the need for treatment and the 
availability of existing services. CSAT's capacity expansion 
grants target population cohorts who are at high risk for sub- 
stance abuse-related morbidity and mortality, such as adoles- 
cents (aged 10-18); racial and ethnic minority populations 
(any age or gender); women, their infants and children; the 
homeless or runaways; and residents of rural areas or migrant 
farm communities. 

Target Cities Program. Under the Target Cities Program, 
States apply on behalf of major cities for funding to (1) de- 
velop central intake, assessment, and referral units; (2) im- 
prove patient/client tracking systems; (3) facility improve- 
ments; (4) formal coordination of treatment and recovery 
programs with health, human services, education, criminal 
justice, and other agencies; and (5) staff training and develop- 
ment. Central intake, assessment, and referral systems are a 
mandatory component of the program. 

Critical Populations Programs. CSAT funds demonstration 
projects for treatment program/treatment system enhance- 
ments that are geared toward adolescents, racial and ethnic 
minority populations, residents of public housing and the 
homeless, women, their infants and children, and rural popu- 
lations. CSAT funds the following program components: (1) 
enhanced outreach methods; (2) provision of onsite primary 
medical care or establishment of formal arrangements for pro- 
viding acute medical care; (3) testing for HIV/ AIDS and sexu- 
ally transmitted diseases; (4) staff training; (5) health education 
(including AIDS education); (6) life-skills counseling; (7) edu- 
cational and vocational counseling; (8) enhanced recovery sup- 
port (including alcohol- and drug-free cooperative housing 
post-residential treatment); (9) psychological and psychiatric 
services for patients with mental disorders; and (10) facility 
improvements. 



Criminal Justice Programs. CSAT funds demonstration 
projects for treatment program enhancements that are geared 
toward substance abusers in the criminal justice system in one 
or more of the following areas: (1) improved coordination of 
all facets of the criminal justice system (i.e., courts, jails, social 
services) and treatment systems; (2) policies and procedures 
for diverting arrestees into treatment in lieu of incarceration; 
(3) onsite provision of alcohol and other drug treatment ser- 
vices in a jail or prison setting; (4) primary medical care (in- 
cluding HIV/ AIDS testing, counseling, and prevention); and 
(5) educational counseling and job training services. 

Treatment Campus Program. Under this program, cooper- 
ative agreements are established between States and CSAT to 
establish campuses. The goals of the campus program are (1) 
to enhance treatment capacity; (2) to improve the quality of 
treatment, especially through the provision of primary med- 
ical care and HIV/ AIDS testing, counseling, and prevention; 
and (3) to create a controlled environment for the assessment 
and evaluation of the efficacy of differing approaches to resi- 
dential treatment. The total patient/client population on each 
campus will eventually be 350. 

Programs for Women, Their Infants and Children. In FY 

1993, the Alcohol, Drug Abuse, and Mental Health Adminis- 
tration (ADAMHA) Reorganization Act authorized CSAT to 
establish programs that assist in providing comprehensive sub- 
stance abuse treatment in residential settings for women, their 
infants and children, including housing that permits children 
to reside with their mothers. 

These treatment services to or on behalf of women will in- 
clude (1) prenatal and post-partum health care; (2) pediatric 
care, counseling, and other mental health services; (3) parent- 
ing training; (4) counseling on AIDS, domestic violence, sex- 
ual abuse, and employment; (5) counseling to assist re-entry 
into society; and (6) case management services. 

HrV/AIDS Outreach Program. This 3 -year program is de- 
signed to (1) seek out injecting drug users (IDUs), other high- 
risk substance abusers, and their sex partners and encourage 
entry into and arrange for treatment of chemical dependency; 

(2) provide medical diagnostic services for HIV/ AIDS and re- 
lated illnesses (e.g., sexually transmitted diseases and TB); and 

(3) provide information, skills, and other prophylactic means 
to effect behavior changes most likely to decrease the risk of 
acquiring or transmitting HIV and related diseases. The goal 
of the program is to demonstrate replicability and cost-effec- 
tiveness of community-based intervention strategies (models) 
and to determine if these modified behaviors produce changes 
in the incidence of HTV and related diseases in the targeted 
populations and communities. 

Resource Development Programs. CSAT has implemented 
a wide array of resource development programs, all of which 
are designed to improve service delivery. 

State Systems Development Program. CSAT created a 
State Systems Development Program (SSDP) to enhance ac- 
countability for State management of substance abuse treat- 
ment and prevention programs. SSDP involves (1) develop- 
ment of statewide substance abuse treatment and prevention 
plans, (2) State assessments of the State's needs for substance 



@ 



Prevention '93/'94: Federal Programs and Progress 



abuse treatment and prevention programs, (3) onsite State 
performance and technical reviews, (4) targeted technical as- 
sistance to States, and (5) creation of a national data base of 
current State treatment and prevention information. SSDP 
monitors State compliance with statutory requirements for 
using block grant funds and State expenditures at the provider 
level. The program also provides assistance to States in match- 
ing treatment and prevention needs and service capacity to 
optimize the provision of appropriate services. 

Primary Care/Substance Abuse Linkage Program. This 

program is designed to strengthen the linkages between the 
primary health care arena and the alcohol, drug abuse, and 
mental health (ADM) treatment systems. Under this program, 
CSAT has convened regional workgroups of medical and 
ADM consortia and practitioners, which have identified major 
issues, barriers, and constraints that interfere with close and 
essential collaboration between primary medical care and 
ADM providers. A national steering committee was formed to 



provide guidance for the 1992 Secretarial Conference of the 
Substance Abuse Linkage Initiative. Another component of 
this program is a Federal demonstration grant program in FY 
1993 that focuses on the delivery of primary health care ser- 
vices in ADM treatment environments. HIV/AIDS testing, 
counseling, prevention, and treatment constitutes a requisite 
component of this program. CSAT will also be working with 
medical and professional organizations to provide education 
and training in substance abuse. 

Institutional and Professional Training and Education 
Program. CSAT is implementing a nationwide counselor 
training effort as an adjunct to the Center for Substance Abuse 
Prevention's (CSAP) National Training System. In FY 1993, 
CSAT will expand a program designed to expose minority 
medical students, substance abuse counselors, and other 
health professionals to addiction treatment environments 
through participation in summer and in-term fellowships in 
addiction treatment programs. 



^) 



Agency Innovations 



Other DHHS Agencies 



Administration on Aging 

(AoA) ^ g 



The Administration on Aging supports State 
and local efforts to address health care, 
economic, and social concerns of older 
Americans through the network of State 
and Area Agencies funded under the Older 
Americans Act. In addition, AoA funds a 
number of discretionary research and demonstration projects 
to carry out annual priorities. 



AoA Prevention Highlights 

National Eldercare Institute on Health Promotion. In 

1991, AoA entered into a 3 -year cooperative agreement with 
the American Association of Retired Persons to fund the Na- 
tional Eldercare Institute on Health Promotion (NEIHP). 
NEIHP is designed to encourage healthy behaviors, reduce 
the risks for chronic and preventable conditions, and main- 
tain and improve functioning among physically and/or men- 
tally impaired older persons. NEIHP (1) serves as a knowl- 
edge base and program resource on health promotion, disease 
prevention, and disability prevention for older persons; (2) 
promotes the effective transfer, dissemination and utilization 
of relevant information on health promotion to audiences 
across the continuum of care; and (3) provides training and 
technical assistance on health promotion and aging, focusing 
on the aging network. Meharry Medical College is encourag- 
ing community outreach and assisting the Institute in its 
focus on minorities. Under the joint sponsorship of AoA and 
NLA, NEIHP has brought together an interagency work- 
group on health promotion with members from a number of 
PHS agencies and other Federal departments. 

Prevention Activities for Older Minorities. NEIHP has 

published Black Elders and Health-Related Issues: A Focus Group 
Study and Hispanic Elders Discuss Health Interests and Needs, 
which focus on attitudes and barriers toward health promo- 
tion and health promotion messages, and a training manual, 
Delivery of Health Promotion Programs: Outreach to Minority El- 
ders, which provides background information related to the is- 



sues and concerns of minority elders and strategies for reach- 
ing the various groups. It offers practical ideas about how to 
apply this knowledge to program planning and implementa- 
tion. A Guide to the Development of Health Promotion Programs 
for Minority and Low-Income Adults is being developed to stim- 
ulate development of health promotion programs for minority 
and low-income elders. 

Meharry Medical College has been conducting community 
forums targeted at predominantly low-income black urban 
and rural populations in Nashville, Tennessee. The forums, 
which covered heart disease, glaucoma, depression, cancer, 
nutrition, and exercise, were carried on VIACOM, the Na- 
tion's largest television cable company. In addition, Meharry 
will be developing a manual on how to develop a community 
outreach program. 

National Council on Patient Information and Education 
(NCPIE). Sponsored by NCPIE, the Talk About Prescrip- 
tions Month campaign publicizes the importance of proper 
use of medications to professional health care providers and 
other caregivers involved with medication management. Arti- 
cles about medication management for older persons and a 
planning guide are distributed to over 15,000 health and aging 
professionals concerned with caregiving for older persons. 

National Osteoporosis Foundation (NOF). National Os- 
teoporosis Week in May is an opportunity to reach millions of 
Americans with osteoporosis awareness, prevention, and treat- 
ment messages. Over the past 6 years, NOF has printed kits 
on prevention activities. NOF also disseminates materials 
from a project that AoA funded in 1991. Entided "Bonewise," 
the purpose of this project is to educate older persons and 
their caregivers about the signs and symptoms of osteoporosis, 
how to prevent it, and how to live with it. 

Nutrition Services for the Elderly. AoA's nutrition program 
supports Area Agencies on Aging in providing nutritionally 
sound meals and other nutrition-related services to elderly 
people and their spouses. Some 250,000,000 meals are served 
to older Americans per year, 40 percent to homebound elderly. 



dti^ 



Prevention '93/'94: Federal Programs and Progress 



National Eldercare Institute on Nutrition. The National 
Eldercare Institute on Nutrition was established in 1991 as a 
3 -year cooperative agreement between the AoA and the Na- 
tional Association of Nutrition and Aging Services Programs 
(NANASP). Other partners include the National Association 
of Meals Programs, the National Association ol State Units on 
Aging, the National Meals on Wheels Foundation, the 
DuPont Corporation, Ross Laboratories, and the Nestle Cor- 
poration. The Institute provides policy and issue analysis, 
public information materials on the nutrition needs of the at- 
risk elderly, and technical assistance to State aging networks 
and community-based long-term care staff, private sector food 
and packaging corporations, and other organizations. The In- 
stitute is conducting a series of futures symposiums to develop 
a strategic plan to provide a blueprint for nutrition services in 
the year 2000 and beyond. A scientific research conference for 
gerontological nutrition professionals, sponsored by the Insti- 
tute and Nestle USA, was held in spring 1993. 

Mental Health. Beginning in FY 1993, AoA is developing 
and training programs to meet the needs of older persons at 
risk of mental health impairment in areas that are underserved 



by mental health professionals. The programs will train 
clergy, primary health care professionals, social workers and 
aides, and community volunteers, to detect risk factors and be- 
haviors characteristic of depression and other disorders among 
frail elderly and to communicate this information to mental 
health care professionals. 

Elder Abuse. AoA's elder abuse strategy consists of State 
Long-Term Care Ombudsman, Elder Abuse Prevention Pro- 
grams, and the National Eldercare Institute on Elder Abuse 
and State Long-Term Care Ombudsman Sen-ices. The 1992 
amendments to die Older Americans Act require AoA to es- 
tablish a National Center on Elder Abuse and a National 
Long-term Care Ombudsman Resource Center in 1 994. 

Eldercare. Project CARE community coalitions were estab- 
lished in approximately 800 communities to focus on a specific 
need of the elderly and what public/private collaboration can 
do to serve them. Thirteen National Eldercare Institutes were 
established under a 3-year cooperative agreement to build the 
knowledge base and provide technical assistance to these 
coalitions. 



^^ 



Agency Innovation 



Administration for Children 
and Families (ACF) 



Established in April 1991, the Administration for 
Children and Families (ACF) is the Federal 
agency that focuses on the needs of America's 
children and families. ACF provides national 
leadership and direction in the administration 
of assistance and services programs designed to 
promote family stability, self-sufficiency, responsibility, and 
economic security. These programs focus on improving the 
well-being of low-income families, neglected and abused chil- 
dren and youth, Native Americans, and individuals with life- 
long disabilities. 



Administration on Children, 
Youth, and Families (acyf) 

The Administration on Children, Youth, and Families is 
made up of four major offices and administers more than 20 
statutory programs serving children, adolescents, and families. 

Head Start 

Head Start is a national program that provides comprehen- 
sive developmental services for America's low-income 
preschool children and their families. Each Head Start pro- 
gram must provide (1) education; (2) parent involvement; (3) 
social services; and (4) health, including medical, dental, men- 
tal health, and nutritional services. Together, these compo- 
nents play an important part in the prevention and ameliora- 
tion of health problems, including mental health, among 
Head Start children. Over 600,000 children are enrolled in 
over 3 1 ,000 Head Start classrooms. 

Through the health component ot Head Start, children re- 
ceive physical examinations, including vision, hearing, and 
blood tests, immunizations, and referrals for treatment and 
other services. When screening or referrals indicate that a 
child may have a disability, evaluations are conducted, individ- 
ualized education programs are written, and services are pro- 
vided to reduce the effect, overcome the problem, and prevent 
secondary disabilities. Mental health services in Head Start are 
aimed at reducing the often high levels of stress that nega- 
tively affect children and families participating in the pro- 
gram. Through the parent involvement component, Head 
Start parents learn how to promote their children's healthy 



development. Parents also receive information on, and refer- 
rals to, local health resources. 

Head Start programs are center-based or home-based. The 
Parent and Child Centers are home-based and provide com- 
prehensive services to pregnant women and families with chil- 
dren from birth to age 3 to improve the overall development 
of the child, prevent developmental deficits, and increase par- 
enting knowledge and skills. 

In addition, the Head Start program has awarded demon- 
stration grants that focus on prevention. Some 66 Head Start 
grantees have established Family Service Centers focusing ef- 
forts on reducing and preventing substance abuse and attain- 
ing" self-sufficiency. These projects serve approximately 4,700 
Head Start families each year. Also, 32 Head Start grantees re- 
ceived funds to establish Family Support Projects to address 
substance abuse problems among both Head Start families and 
staff. Funds were also provided to another seven Head Start 
grantees, located in cities that receive funding from the Office 
of Treatment Improvement's Target Cities Program, to im- 
prove treatment and support for Head Start families affected 
by substance abuse. 

Through the 22 Head Start-State collaboration projects the 
goal is coordination among programs serving low-income 
children and families at the Federal, State, and local levels, es- 
pecially the Medicaid Early and Periodic Screening, Diagnosis 
and Treatment Program (EPSDT) is a goal. Nine Head Start 
programs were awarded grants to work in collaboration with 
other Federal, State, and local programs, as well as private 
providers, to improve access to immunization services for in- 
fants and toddlers in Head Start families. 

Children's Bureau 

Child Care and Development Block Grant (CCDBG). 

The Child Care and Development Block Grant is one of the 
major child care programs administered by ACF. Funds are 
available to States, Territories, and Indian tribes to provide 
grants, contracts, and certificates for child care services. The 
purpose of the CCDBG is to increase the availability, afford- 
abilitv, and quality of child care for low-income families and 
to increase the availability of early childhood development 
services and before- and after-school care. To be eligible, a 
family must be low-income and need child care either because 
a parent is working or attending a training or educational pro- 
gram or because the family receives or needs to receive pro- 



flff^ 



Prevention '93/'94: Federal Programs and Progress 



^^ 



tective services. For FY 1993, Congress allocated $ 893 mil- 
lion for the CCDBG program. 

Abandoned Infants Assistance Act. The purpose of this 
program is to fund model demonstration projects to prevent 
the abandonment of infants and children, particularly those 
who have been exposed to substance abuse and/or who test 
positive for HIV/AIDS. 

National Center on Child Abuse and 
Neglect (NCCAN) 

ACF's child abuse and neglect programs provide both for- 
mula and discretionary grants to States and community-based 
entities to improve and increase activities for the prevention 
and treatment of child abuse and neglect. The National Cen- 
ter on Child Abuse and Neglect is the focal point within ACF 
for efforts to identify, prevent, and treat child abuse and 
neglect. 

NCCAN administers six separate programs to assist States 
and local communities to initial and improve prevention and 
treatment programs. 

Community-Based Child Abuse and Neglect Prevention 
Grants. Formerly the Child Abuse Prevention Challenge 
Grants, this program provides funds to States only for child 
abuse prevention activities. Other State grant programs pro- 
vide funds to support efforts to prevent the medical neglect of 
children, particularly medically fragile infants; to improve the 
process of preventing, investigating, and prosecuting child 
abuse cases, particularly child sexual abuse; and to develop and 
strengthen basic child abuse and neglect prevention and treat- 
ment programs. 

Current NCCAN-funded research, demonstration, and 
training projects include model approaches to child abuse and 
neglect services in rural areas; an evaluation of Hawaii's edu- 
cation and support program for new parents to prevent child 
abuse and neglect; a national replication project to raise public 
awareness about the dangers of shaking babies; and demon- 
stration projects that address effective parenting skills and 
provide support for parents in the prevention of child abuse 
and neglect. 

Continued support is being provided to nine Comprehen- 
sive Community-Based Child Abuse and Neglect Prevention 
projects. Initially funded in FY 1991 and continuing through 
FY 1994, these grants support the planning and development 
of model physical child abuse and neglect prevention pro- 
grams designed to address local needs in urban, suburban, 
and rural communities. The service components include pub- 
lic awareness campaigns, support services for parents under 
stress, parental health care, parental education, and the pre- 
vention ol alcohol and drug-related child abuse and neglect. 

The Emergency Child Abuse and Neglect Prevention Ser- 
vices Grants provide prevention and intervention seniles to 
children and youth who are victims or at risk of child maltreat- 
ment by parents who are substance abusers. Project activities 
include specialized training for protective service workers; co- 
ordinated, comprehensive multidisciplinary service delivery 
models; information/education projects regarding the relation- 
ship between substance abuse and child abuse; and projects to 
improve service delivery to children ol substance abusers and 
in remove barriers to treatment of the parents' addiction. 



Family and Youth Services 
Bureau (FYSB) 

An estimated 500,000 to 1.5 million young people in Amer- 
ica are runaways or homeless, often through no fault of their 
own. As a result, they are exposed to the exploitation and dan- 
gers of street life including crime, prostitution, and substance 
abuse. The programs administered by the Family and Youth 
Services Bureau offer prevention and intervention strategies 
to help at-risk youth and their families overcome the negative 
aspects of their life situations and to become competent, inde- 
pendent, drug-free adults who maintain themselves, outside 
the social welfare system. 

Runaway and Homeless Youth Program. Through approx- 
imately 360 Basic Centers nationwide, staff try to reunite 
youth with their families whenever possible or to arrange al- 
ternative, safe placements when such reunification is not pos- 
sible. All Centers provide crisis intervention, shelter, food, 
clothing, outreach; counseling, and family reunification and 
aftercare services to runaway and homeless youth and their 
families. Services also include prevention activities related to 
substance use and abuse, sexuality, sexually transmitted dis- 
eases, and HIV/AIDS. 

Through approximately 100 projects nationwide, the Drug 
Abuse Prevention Program for Runaway and Homeless 
Youth supports research, demonstration and service efforts to 
prevent and reduce the use of illicit drugs by runaway and 
homeless youth. These projects most often work with emer- 
gency shelters or transitional living programs to provide fam- 
ily, group, and peer counseling; communitv education and 
outreach; and training for youth workers. Research efforts in- 
clude studies of illicit drug use by runaway and homeless 
youth, the effects of substance abuse on family members, and 
the correlation between youth substance abuse and suicide. 

The Transitional Living Program for Homeless Youth 
supports approximately 90 comprehensive projects nationwide 
in which homeless youth, in a supervised setting for up to 18 
months, receive training in lite skills. The training includes 
courses in social and emotional development, employment 
orientation, and entry or re-entry into appropriate education 
programs along with emphases on maintaining physical, men- 
tal health and proper nutrition. 

The Youth Gang Drug Prevention Program supports 
approximately 50 projects nationwide aimed at diverting at- 
risk youth from gang membership and reducing and prevent- 
ing drug trafficking. Specific prevention activities include 
promoting the involvement of youth in lawful activities in 
communities in which gangs commit drug-related crimes; ed- 
ucating youth about drug abuse: providing support to police, 
schools, employment and social service agencies in their out- 
reach, referral, treatment, and rehabilitation efforts; and pro- 
viding training and technical assistance to \outh workers. 



Office of Family Assistance (ofa) 

OFA is responsible for several programs that help low - 
income families to meet their immediate financial needs and 
to become ami remain economical!;, and sociall} sell-suffi- 
cient. The programs include the Vid to Families with Depen- 
dent Children i \FDC) and the Job Opportunities .\nd Basic 
Skills Training (JOBS) programs. AJFDC provides recipients 



Agency Innovations 



with automatic eligibility for Medicaid. JOBS helps AFDC re- 
cipients to achieve self-sufficiency and also provides a year of 
transitional Medicaid benefits. 



OFA Prevention Highlights 

A few States have received waivers of AFDC statutory pro- 
visions to operate demonstration programs involving preven- 
tive health care requirements. For example, Georgia has an 
approved demonstration project called the Preschool Immu- 
nization Project that requires families to immunize preschool 
children or have AFDC benefits reduced. The Alabama 
AFDC Demonstration Project is designed to test the effec- 
tiveness of two outreach and education programs on the 
measles immunization coverage levels of preschool-age chil- 
dren. Maryland applies fiscal sanctions to AFDC cases that do 
not comply with specific requirements related to preventive 
health care: that preschool-age children must receive sched- 
uled Early and Periodic Screening, Diagnosis and Treatment 
(EPSDT) services; school-age children and adults must re- 
ceive annual preventive health check-ups; and pregnant 
women must receive regular prenatal visits. 



Office of Child Support 
Enforcement (ocse) 

The Child Support Enforcement program, which is admin- 
istered by OCSE, reduces welfare dependency, encourages 
continuing family relationships, and promotes individual 
parental responsibility for the financial support of their chil- 
dren by locating absent parents, establishing paternity, and es- 
tablishing and enforcing support obligations. 

OCSE Prevention Highlights 

Paternity establishment is an important part of the Child 
Support Enforcement program. Children benefit psychologi- 
cally, socially, and economically when paternity is established. 
Medical support is a part of support orders established against 
parents. In FY 1992, 515,429 paternities were established. 



Administration on Developmental 
Disabilities (add) 

ADD funds efforts to advocate for and coordinate the ex- 
pansion of the social and economic integration into society of 
the almost 4 million Americans with severe mental or physical 
disabilities under the age 22. 

ADD Prevention Highlights 

University Affiliated Programs (UAPs). The University 
Affiliated Programs are authorized under the Developmen- 
tal Disabilities and Bill of Rights Act. Through awards made 
to 58 universities and satellite centers, ADD supports the 
development, coordination, and implementation of preven- 
tion activities through education and community-based ac- 
tivities. These include the interdisciplinary training of per- 



sonnel and the demonstration and dissemination of findings 
related to the provision of services to persons with develop- 
mental disabilities. Specific prevention activities include 
early intervention services; counseling and training of par- 
ents; early identification, diagnosis, and evaluation of devel- 
opmental disabilities; and projects to modify violent and 
abusive behavior. 

Projects of National Significance. ADD funds a variety of 
projects that address the impact of HIV and MDS on the lives 
of children, adolescents, and adults with developmental dis- 
abilities, including the health and social service needs of chil- 
dren with HIV or MDS. Other projects have been funded to 
develop tools and procedures for the analysis and assessment 
of State policies and practices on the prevention of develop- 
mental disabilities; to promote best practices in early identifi- 
cation and provision of services to children with disabilities; 
and for the identification, prevention, and treatment of sub- 
stance abuse, including tetal alcohol syndrome. 

The Home of Your Own is a set of basic principles devel- 
oped by ADD to enable more positive futures for people with 
disabilities and their families, and several cultural diversity 
projects designed to assure that agencies serving persons with 
developmental disabilities are aware of and address the needs 
of ethnic/racial minorities. 

Developmental Disabilities Planning Councils. ADD pro- 
vides formula grant funding to 56 States and jurisdictions for 
the purpose of supporting a Developmental Disabilities Plan- 
ning Council. Established to assist States in developing and 
implementing a comprehensive plan for meeting the needs of 
persons with developmental disabilities, the Councils advocate 
for coordination of activities for the prevention of develop- 
mental disabilities, especially early intervention services for 
infants, toddlers, young children, and families. 

Protection and Advocacy Systems (P&As). The Protection 
and Advocacy Systems operate in each State and Territory to 
provide legal, administrative, or other solutions to resolve is- 
sues for individual and class action clients. In addition to advo- 
cacy services, P&As provide information, referral services, 
training, and technical assistance activities to people with de- 
velopmental disabilities, their families, or guardians. 



Office of Community Services (ocs) 



OCS Prevention Highlights 

Social Services Block Grant Program (SSBG). The major 
source of Federal funding for State social services programs is 
the Title XX Social Services Block Grant. For FY 1992-1994, 
$2.8 billion is authorized for this program. SSBG goals in- 
clude self-support or self-sufficiency; preventing or remedying 
the neglect, abuse, or exploitation of children and adults un- 
able to protect their own interests; and preventing or reducing 
inappropriate institutional care. States determine the services 
to be provided and the eligibility criteria; typical preventive 
services include home-based services (home-maker, home 
health, and chore services) to prevent abuse and neglect and 
bring about family stability; health-related services, including 



ffi) 



Prevention '93/'94: Federal Programs and Progress 



preventive medical care and in-home health services; counsel- 
ing, including mental health services; family planning; and 
substance abuse services. 

Low-Income Home Energy Assistance Program 

(LIHEAP). These funds are distributed to States, Territories, 
and Indian tribes to assist low-income households in meeting 
the costs of home heating and cooling. Grantees are required 
to set aside "a reasonable amount" of funds each year for en- 
ergy crisis intervention. 

Community Services Block Grant (CSBG). For FY 1993, 
$372 million was made available through 124 block grants 
to States, Territories, Indian Tribes, and tribal organiza- 
tions to address problems faced by low-income persons in 
the areas of employment, education, housing, food and nu- 
trition, energy, emergency services, and health. Under the 
CSBG discretionary authority, States, public agencies, and 
private nonprofit organizations receive funds that provide 
services such as affordable, adequate, and safe water and 
waste water treatment facilities in low-income rural com- 
munities; health and nutrition programs for migrants and 
seasonal farm workers; and the National Youth Sports Pro- 
gram, which provides a comprehensive developmental and 
instructional sports program, including nutritional and 
medical components, serving over 61,000 low-income 
youth. 

Community Food and Nutrition Program. This program 
provides assistance to public and private agencies at the State 
and local levels to initiate nutrition programs for low-income 
individuals. 

Emergency Community Services Homeless Grants. 

Grants are awarded to States and Indian tribes for programs to 
assist the homeless and help them make the transition out of 
poverty. 



Office of Refugee 
Resettlement (orr) 

The Office of Refugee Resettlement, in partnership with 
the States, national voluntary resettlement agencies, and 
refugee-based mutual assistance associations, assists refugees 
to achieve economic self sufficiency after resettlement in the 
United States. To be designated as refugees, individuals must 
have a well-founded fear ol persecution in their country of 
residence due to race, religion, nationality, or political opin- 
ion. In FY 1992, approximately 141.000 refugees and Am- 
erasians were admitted to the United States. 

ORR Prevention Highlights 

Refugees may have health problems due to environmental 

conditions and lack of medical care that may exist in their 
country of origin. In addition, refugees may experience 
health problems in the camps while wailing for resettle 
ment. The Department of State provides funding lor med- 
ical screening ol refugees prior Co entrj into the United 
States. 



Refugee medical problems may affect the public health as 
well as prevent refugees from achieving economic self-suffi- 
ciency In 1992, over S5.6 million was expended to review 
medical records at the port-of-entrv to ensure that refugees 
received prompt attention and to reimburse States for cost in- 
curred in providing health assessments to refugees and treat- 
ment for refugees with medical conditions. 



Administration for Native 
Americans (ana) 

Under the Native American Programs Act of 1974, compet- 
itive financial assistance is available to promote social and eco- 
nomic self-sufficiency for American Indians. .Alaska Natives. 
Native Hawaiians, and Native .American Pacific Islanders. 

ANA Prevention Highlights 

ANA funding supports Indian tribal governments and 
other Native American organizations in the development of 
community-based social and economic development strate- 
gies. The social development goal is to support local access 
to, and coordination of, services and programs that safeguard 
the health and well-being of people in the community. Exam- 
ples of health-related objectives in a number of projects in- 
clude efforts to reduce the incidence of alcohol and drug 
abuse and to increase access to health sen-ices. ANA is con- 
tinuing its Native American Youth .Alcohol, Drug, and Smok- 
ing Prevention Initiative with a national Campaign for 
Healthy Lifestyles, which is a holistic approach to prevent al- 
cohol and other substance use and abuse, and a specific 
youth-generated national War on Alcohol, which was 
launched in early 1993. 



President's Committee on Mental 
Retardation (pcmr) 

The President's Committee on Mental Retardation is man- 
dated by Executive Order to "evaluate the status ot the na- 
iiiin.il effort to combat mental retardation" ami "develop and 
disseminate such information as will tend to reduce the inci- 
dence of mental retardation and ameliorate its effects." 
PCMR acts in an advisory capacity to the President and the 
Secretary of Health ami 1 Iuinan Services on critical matters 
regarding programs and services lor persons with mental re- 
tardation. In addition, PCMR coordinates Federal agency ac- 
tivities in mental retardation; conducts studies <>t existing pro- 
grams; and highlights the need for changes, where 
appropriate; and promotes research. 

PCMR Prevention Highlights 

Ihe Committee's Annual Report to the President focuses 
on reducing the incidence and prevalence ol disabilities, par- 
ticular!) when socioeconomic conditions are known to be 
contributing factors. The report concentrates on the new 
morbidities, i.e.. any combination of mental, physical, social, 
educational, health, environmental, and psychosocial condi- 



Agency Innovations 



tions that result from socioeconomic disadvantage and, to- 
gether, render a child at risk of developing mental retardation 
or related disabilities. The report gives the status of the na- 
tional effort to minimize the occurrence and ameliorate the 
effects of mental retardation and identifies agencies, organiza- 
tions, foundations, and institutions that are implementing ser- 
vices known to be effective in preventing disabilities. 



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Prevention '93/'94: Federal Programs and Progress 



Health Care Financin 



Administration (HCFA) 




The Health Care Financing Administration 
(HCFA) manages both the Medicare pro- 
gram and the Federal portion of the Medic- 
aid Program, which is iointlv funded but di- 
rectly administered by the States. While 
Medicare serves virtually all people over 65 
in the country, the Medicaid program provides health care 
benefits primarily to low income families and certain groups 
of the aged and disabled. HCFA stresses the timely delivery of 
appropriate, quality health care to its beneficiaries — for 1993 
an estimated 36.2 million Medicare clients and 31.5 million 
Medicaid recipients. Through the promotion of coordinated 
care systems Medicaid maternal and child health initiatives, a 
variety of other Medicare and Medicaid benefits and innova- 
tive research and demonstration projects, HCFA programs 
also emphasize disease prevention and health education. Their 
strong preventive care orientation enhances the quality of life 
for beneficiaries and slows the rise in health care costs. 



HCFA Prevention Highlights 

Medicaid Program. Title XIX of the Social Security Act pro- 
vides for a program of medical assistance, ".Medicaid," for cer- 
tain individuals and families with low incomes. This means- 
tested entitlement program was enacted in 1965 as a jointly 
funded Federal and State cooperative venture. Within broad 
Federal guidelines, each State determines (1) its own eligibil- 
ity requirements; (2) the amount, duration, and scope of ser- 
vices to be covered; ami (3) the rate-setting methods and levels 
ol service reimbursement. Since each State also administers its 
own program, Medicaid programs vary from State to State. 

Medicaid covers and facilitates the provision of preventive 
health services in three ways: (I) as an integral component of 
its required comprehensive child health program for eligible 
beneficiaries under 21, known as Early anil Periodic Screen- 
ing, Diagnosis, and Treatment (EPSDT); (2) as an integral 
component ol mandatory Medicaid services such as physician, 
laboratory and x-ray, and outpatient hospital services; ami (3) 
through certain optional services, such as clinic services, op- 
tometrist services, or the preventive services benefit. Cur- 
rently, 2X States offer these optional services. 

Medicaid's EPSDT program requires Slates not onl) to li 
nance but to develop and manage a comprehensive health pro 
gram that assesses children's health needs through initial and 
periodic examinations/screenings. These examinations/ 



screenings include comprehensive histories and physical 
exams, counseling, age-appropriate immunizations, tuberculo- 
sis skin testing when appropriate, and laboratory tests includ- 
ing lead screening tests. The Medicaid Child Health Initiative 
is designed to improve participation in the EPSDT program 
and involves the efforts of many PHS agencies. 

For women's preventive health sendees, all States and the 
District of Columbia cover cervical cancer screening and fol- 
low-up services for abnormal Pap smears. Currently, 47 juris- 
dictions cover mammography screenings and all jurisdictions 
cover medically necessary mammography. 

Virtually all Medicaid managed care programs, whether pri- 
mary care case management systems or capitated health main- 
tenance organizations, emphasize preventive services such as 
periodic health check-ups, immunizations, mammography, 
and cervical cancer screening. Increased enrollment in Medi- 
caid managed care programs is a key program priority, so that 
coordinated care, rather than unfettered fee-for-service. will 
be the norm. The number of Medicaid managed care en- 
rollees increased to 3.6 million in 1992, up 35 percent from 
1991. 

Federally Qualified Health Centers (FQI ECs) was added as a 
separate mandated benefit to the .Medicaid program, effective 
April 1, 1990. This expanded the availability of covered .Medic- 
aid services to recipients who use the Community, Migrant, or 
Homeless Health Center programs. The Centers, which are 
established under PHS grant-funded programs, focus on deliv - 
cry of primary and preventive health care services to communi- 
ties that are medically undersencd or that have shortagi 
medical manpower. Expanded Medicaid payments for services 
under the FQ] [C benefit enabled the (".enters to provide more 
health services in the people the) serve, both Medicaid recipi- 
ents and other people with low-incomes. 

Medicare Program. On October 1. 1991, a new benefit be- 
came available to Medicare beneficiaries w ho obtain services 
at a FQHC. This new benefit covers .1 wide range ot preven- 
tive services. 

To provide Medicare beneficiaries with opportunities for 
the early detection ol cervical and breast cancer, the Pap 
smear screening benefit was established effective July 1. 1990, 
and the mammography screening benefit was added to the 
program effective January 1. 1991. The Pap smear screening 
benefit includes coverage of a clinical laboratory's evaluation 
of the sample .^ni\ (when necessary) a pathologist's interpreta- 
tion ot the sample. It allows lor coverage ot one Pap smear 



^fo 



Agency Innovations 



screen every 3 years, or more often when there is evidence 
that the beneficiarv is at high risk of developing cervical can- 
cer and her physician recommends that she be tested more 
frequently. The mammography screening benefit provides for 
coverage of a radiological procedure and a physician's inter- 
pretation of each film or image. The frequency of coverage of 
these screening services is limited according to a patient's age. 
In the case of women over age 34 but under age 40, coverage 
frequency also is based upon whether individuals are consid- 
ered to be at high risk of developing breast cancer on the basis 
of their family and personal medical history. 

Most Medicare beneficiaries enrolled in HMOs under 
HCFA's coordinated care program receive preventive services 
not covered under fee-for-service Medicare, such as annual 
physical exams, certain immunizations, vision and hearing 
tests, colorectal screenings, and health education. 

Research and Demonstration Projects. HCFA has several 
ongoing research and demonstration projects. 

A 6-year cooperative agreement awarded to the University 
of North Carolina was concluded in 1992. The project used 
randomized trials with four comparison groups: clinical 
screening only, health promotion only, clinical screening plus 
health promotion, and usual care. The clinical screening pack- 
age included services such as blood pressure checks, vision and 
hearing tests, and a medical history. The health promotion 
sendees include counseling on such topics as physical activity, 
nutrition, and falls and accident prevention. The final report 
reveals that beneficiaries receiving the interventions experi- 
enced small, positive gains in health and quality of life indica- 
tors relative to beneficiaries in the control group at the 2 -year 
follow-up. However, the study determined the preventive ser- 
vices intervention to be cost neutral. 

Section 4071 of the Omnibus Budget Reconciliation Act 
(OBRA) of 1987 mandated that the Secretary of Health and 
Human Sendees conduct a demonstration to test the cost-ef- 
fectiveness of including influenza vaccine as a covered treat- 
ment under Medicare. HCFA worked with CDC to imple- 
ment the demonstration in 1988. OBRA '87 also mandated a 
demonstration to test the cost-effectiveness of providing ther- 
apeutic shoes to Medicare beneficiaries with severe diabetic 
foot disease. The demonstration was implemented in 1989. 



Both the influenza vaccine and therapeutic shoe demonstra- 
tions continued through October 1992. Evaluation of the in- 
fluenza vaccine concluded with a report to Congress in April 
1993 showing that under certain conditions and circumstances 
the vaccine is cost-effective. Coverage of both the influenza 
vaccine and therapeutic shoes began under Medicare in May 
1993. 

The Consolidated Omnibus Budget Reconciliation Act 
(COBRA) of 1985 directed the Secretary to establish a 4-year 
demonstration program designed to reduce disability and de- 
pendency by providing preventive health services to Medicare 
beneficiaries. In May 1988, FICFA awarded cooperative agree- 
ments to the University of Washington, Johns Hopkins Uni- 
versity, San Diego University, the University of Pittsburgh, 
and the University of California at Los Angeles to conduct 
demonstrations under the program. They made available to 
Medicare beneficiaries health screenings, health risk appraisals, 
and immunizations. Also available were counseling on and in- 
struction in diet and nutrition; reduction of stress; exercise and 
exercise programs; sleep regulation; injury' prevention; preven- 
tion of alcohol and drug abuse; prevention of mental health 
disorders; self-care, including use of medications; and reduc- 
tions or cessation of smoking. The demonstrations were re- 
cently extended to allow for an additional year of tracking. The 
final report to Congress is due in April 1995. 

In September 1992, HCFA awarded a research project enti- 
tled "Comparative Study of the Use of EPSDT and Other 
Preventive and Curative Health Care Services by Children 
Enrolled in Medicaid." The purpose of this study is (1) to ex- 
amine the effect of changes in the use of the EPSDT program 
in four States, as a result of OBRA 1989, on the process of 
providing health services to children and the appropriateness 
of expenditures for sendees provided; (2) to compare Medic- 
aid-eligible children enrolled in EPSDT programs with other 
Medicaid-eligible children who are not receiving EPSDT ser- 
vices in terms of service utilization and expenditures, with a 
particular emphasis on preventive health services; and (3) to 
compare children enrolled in the Medicaid program with non- 
Medicaid children, insured and uninsured, on the use of and 
expenditures for preventive services and other health care ser- 
vices, using national survey data. The final report is expected 
September 1995. 



^^ 



Prevention '93/'94: Federal Programs and Progress 



Other Federal Agencies 



^^ 



Department of 
Agriculture (usda) 

The Department of Agriculture administers a variety of 
programs with prevention components, including food and 
nutrition programs. Because of the impact of these programs 
on the lives of millions of Americans, USDA in June 1993 
held the largest federally sponsored hunger symposium since 
the 1969 Conference on Food, Nutrition and Health. The 
forum, which focused on the extent and nature of hunger in 
America, is part of an effort to reinvent the food assistance 
programs to better reach people in need, to promote self-suf- 
ficiency through nutrition education, and to alleviate the nu- 
trition and health consequences of inadequate diets. 

The nutrition guidance offered through the food assistance 
programs is based on the Dietary Guidelines for Americans, 
which were updated and published jointly by USDA and 
DHHS in 1990. 

Prevention activities also focus on food safety, family 
health, and nutrition education. 

USDA Prevention Highlights 

Promotion of the Dietary Guidelines for Americans. 

USDA's Human Nutrition and Information Service (HNIS) 
and DHHS's Office of Disease Prevention and Health Pro- 
motion joindy coordinate the development, publication, and 
distribution of the Dietary Guidelines. HNIS interprets the 
Guidelines for consumer audiences (see Nutrition Education). 
USDA's Food and Nutrition Service implements the Guide- 
lines in the domestic food assistance programs it administers. 
The Extension Service, through its partnership with the Co- 
operative Extension System, uses the Guidelines as the founda- 
tion of its nutrition education programs. 

Food Assistance Programs. USDA's Food and Nutrition 
Service (FNS) administers a variety of food assistance pro- 
grams. The Food Stamp Program supplements the food pur- 
chasing power of needy households. Program benefits are 
based on a low-cost, nutritious diet (The Thrifty Food Plan). 
Other USDA food assistance programs include the National 
School Lunch and School Breakfast Programs; the Child and 
Adult Care food Program, which helps day-care facilities and 
institutions serve nutritious meals to preschool and school-age 
children and certain adults; the Summer Food Service Pro- 
gram, which helps communities serve meals to needy children 
when school is not in session: the Special Supplemental Food 
Program for Women, Infants, and Children (WIC), which 
provides supplemental foods, nutrition education, and health 
care referrals to low-income pregnant, breastfeeding, and 
post-partum women, as well as to infants and children up to 



age 5 who are at nutritional risk; the Commoditv Supplemen- 
tal Food Program, which provides USDA commodities to a 
population similar to the WIC Program, as well as to children 
up to age 6 and low-income elderly persons age 60 and over; 
and the Special iVIilk Program, which makes it possible for 
children attending a participating school or institution to re- 
ceive free milk or purchase it at a reduced rate. Commodity 
distribution programs include the Emergency Food Assistance 
Program, under which needy households receive a variety of 
commodities, and the Food Distribution Program on Indian 
Reservations, which is available in lieu of food stamps to Na- 
tive Americans and their families. 

As a first step in assisting program cooperators to put the 
Dietary Guidelines into practice, USDA, with DHHS, pub- 
lished Building for the Future, Nutrition Guidance for the Child 
Nutrition Programs. Over 475,000 copies have been printed 
and distributed to program cooperators. 

FNS is analyzing the current National School Lunch Pro- 
gram (NSLP) meal pattern to determine if it meets the nutri- 
tional goal of one-third of the 1989 Recommended Dietary 
Allowances for kev nutrients and the 1990 Dietary Guidelines 
for fat, and if it meets appropriate calorie levels. FNS also 
plans to develop and standardize additional quantity recipes 
for the NSLP, which will meet meal pattern requirements and 
reflect the Dietaiy Guidelines. 

In addition, FNS will be testing a nutrient-based menu 
planning system. This alternative approach to menu planning 
requires that school meals meet a specific nutritional stan- 
dard, e.g., one-third of the RDA's, rather than a food-based 
meal pattern. To support this new approach, FNS will work 
with HNIS to develop a National Nutrient Database for the 
Child Nutrition Programs. This data base will be used by the 
software industry to develop nutrient analysis and food ser- 
vice software systems specifically for the Child Nutrition 
Programs. 

Legislation passed in 1989 authorized the USDA to estab- 
lish and maintain a National Food Service Management Insti- 
tute at the University of Mississippi for 5 years, through fiscal 
year 1994. The Institute was founded to improve the general 
operation and quality of Child Nutrition Programs and other 
federally assisted feeding programs through training, technical 
assistance, research activities, and management support. 

In addition, FNS's Nutrition Education and Training Pro- 
gram helps support nutrition education efforts in the Child 
Nutrition Programs. 

Nutrition Education. I 1X1S conducts research on the di- 
etary status of Americans and factors that influence that status, 
including assessments of knowledge and attitudes toward diet 
and health. Results of this research and 1 IN IS research studies 
on communication are used to target nutrition education mes- 
sages to specific audiences. The Food Guide Pyramid released 
in' \pnl 1"": is supported by both USDA and HI 11 IS and has 
been very well received by the professional communitj and 
the public. The food guide, illustrated by the pyramid, was tie- 



Agency Innovations 



veloped bv USDA in the early 1980s to help consumers put 
the Dietary Guidelines for Americans into action in their daily 
food choices. Other HNIS publications that promote this 
healthful eating pattern include: 

HG-2 3 2 Dietary Guidelines for Americans, 3rd edition 

HG-32S La Nutrition y su Salad: Gaias para sn dicta, 

3rd ed. (official Spanish translation) 
HG-2 32-8 Preparing Foods and Planning ft Icmis Using 

the Dietary Guidelines 
HG-232-10 Shopping for Food and Making Meals in 

Minutes Using the Dietaiy Guidelines 
HG-232-1 1 Eating Better When Eating Out Using the 

Dietaiy Guidelines 
HG-2 52 The Food Guide Pyramid 

Through the Food Distribution Program on Indian Reser- 
vations, USDA has developed three nutrition education initia- 
tives for Native Americans. First is a series of 12 fact sheets on 
health and nutrition issues. These publications, which are is- 
sued one per month with the FDPIR food package, also in- 
clude recipes appropriate to each topic. Second, USDA has al- 
located $135,000 to FNS Regional Offices, which use these 
funds either to purchase nutrition education materials for 
agencies that administer FDPIR or to provide competitive nu- 
trition education grants to these agencies. Finally, FNS has 
formed the Interagency Task Force on Nutrition Education 
for Native Americans, which includes nine Federal agencies 
and two national Native American organizations. Through 
collaboration in delivering nutrition education services to Na- 
tive Americans, member agencies intend to avoid overlap, 
conserve resources, stimulate innovation, and ensure effective 
implementation of sound nutrition education strategies. 

The Cooperative Extension System (CES) is USDA's net- 
work for food and nutrition education, reaching adults and 
youth in 3,150 counties in the United States. Educational pro- 
grams provide individuals and families with the knowledge 
base to make informed decisions about food, nutrition, and 
health. Objectives include helping people achieve and main- 
tain optimal weight and reduce risk of chronic disease; give 
birth to healthy babies; practice responsible and healthy self- 
care; help children obtain optimal health; minimize nutri- 
tional inadequacies and abuses in foods; and improve con- 
sumers' ability to make informed choices about food safety, 
quality, and composition. Educational programs are available 
to meet the needs of individuals and families from preconcep- 
tion through old age with materials that are culturally appro- 
priate for the intended target audience. An estimated 10 mil- 
lion people are reached nationwide through nutrition 
education programs. 

Health Promotion. USDA is currently assisting in a study 
with CDC on the effects of smoking reduction programs on 
smoking behavior and pregnancy outcome for women of 
child-bearing age in a local health department setting. In addi- 
tion, the WIC Breastfeeding Study identified effective meth- 
ods for encouraging new mothers to breastfeed their infants. 
USDA also recently completed a major study that suggested 
that participation in WIC can reduce Medicaid costs. 

Since June 1 990, USDA has hosted meetings twice a year of 
a Breastfeeding Promotion Consortium composed of 25 orga- 
nizations, including DHHS. At the Consortium's recommen- 



dation, USDA is embarking on a major breastfeeding promo- 
tion campaign. DHHS will play a major role in this campaign 
through a Memorandum of Understanding with USDA. 

USDA has also produced a comprehensive packet of mate- 
rials (videotapes with print companion pieces, posters, re- 
source manual, and brochure) to assist WIC professionals in 
(1) advising clients about the effects of alcohol and other drugs 
on pregnancy outcomes; (2) screening for possible drug use; 
and (3) referring clients for assessment/counseling. USDA has 
also assisted the CDC in developing a videotape to promote 
immunizations. 

Food Safety Education. USDA's Food Safety and Inspection 
Service provides food safety information to consumers and the 
food service industry. Targeted information is being provided 
to those who are at risk for developing foodborne illnesses. A 
new, free, food safety publication was released that guides 
consumers through those critical food handling steps where 
failure to take appropriate action could result in foodborne ill- 
nesses. New in 1991 was a videotape/workbook program for 
teens, called "The Danger Zone," to be used by home eco- 
nomics, health, and science teachers. The toll-free Meat and 
Poultry Hotline (1-800-535-4555) provides advice to con- 
sumers and identifies areas where consumers are lacking infor- 
mation so that new education programs can be developed. 

The CES also provides food safety educational programs 
(some available in multiple languages) to consumer groups, 
high-risk individuals and food handlers, and the food service 
industry. These programs have two primary approaches. The 
first is to reduce risks present in the food supply by conducting 
educational programs for producers, processors, food han- 
dlers, and consumers to teach them skills required to reduce 
hazards of contamination. The second is to improve public 
understanding about scientific and policy bases for risk man- 
agement decisions. 

Human Nutrition Research. USDA's Agriculture Research 
Service is uniquely equipped to find solutions to national nu- 
trition problems linked to the food supply. Research is di- 
rected to defining the nutrient requirements of humans at all 
stages of life, with emphasis on prevention of diet-related dis- 
orders and promotion of health through improved nutrition. 
Specific efforts are being made to determine the special nutri- 
tional needs of infants, pregnant and lactating women, and the 
elderly. Research is also designed to develop a better under- 
standing of the relationship of nutrition to chronic diseases 
and obesity. 

Youth at Risk. The CES, through a matched funding 
process, provides targeted prevention and intervention pro- 
grams to aid communities in addressing needs of youth at risk. 
To maximize resources and potential impact, programs focus 
on school-age child care and education, coalitions that support 
community programming with high-risk youth, and develop- 
ment of literacy and technological literacy in youth at risk. 

Farm Safety. The CES has developed education programs 
that address all aspects of agricultural safety and health, in- 
cluding prevention of traumatic injury and exposure to health 
hazards; emergency response to farm accidents for the first 
person on the scene and professional rescue personnel; and re- 
habilitation of farmers with disabilities. Since its inception. 



(ffi 



Prevention '93/'94: Federal Programs and Progress 



^^ 



CES has developed educational programs to address agricul- 
tural safety and health issues. These programs educate farmers 
on how to: 

• Reduce their exposure to infectious agents; 

• Prevent farm accidents in working with tractors, ma- 
chinery, livestock, and farm structures; and 

• Reduce the severity of the injuries to farm accident vic- 
tims and rescuers through better rescue and emergency 
procedures. 

In FY 1991, CES began implementing the Education and 
Assistance Program for Farmers with Disabilities. This pro- 
gram's primary objective is to provide unique services not 
readily available to an estimated 500,000 farmers and ranchers 
with disabilities. Its primary effort has been to expand pilot 
programs that have been developed by experts in CES and the 
National Easter Seal Society. 



Department of 
Commerce (doc) 



The Department of Commerce, through the National 
Oceanic and Atmospheric Administration (NOAA), has re- 
sponsibilities to help ensure the safety and quality of fishery 
products. Activities include conducting scientific research; 
conducting a voluntary, fee-for-service seafood inspection 
program; providing information to the seafood industry and 
Federal and State regulatory agencies; and collaborating with 
industry and regulators to develop regulations and seafood 
processing procedures. 



DoC Prevention Highlights 

NOAA conducts research to assess seafood safety risks re- 
lated to marine biotoxins, pathogenic microorganisms, and 
chemical contaminants and to develop prevention and control 
strategies. Recent efforts include development of the Na- 
tional Plan for Marine Biotoxins, in cooperation with other 
Federal agencies and academia. This plan will focus efforts on 
understanding how and why biotoxins occur and developing 
methods to detect contaminated fishery products. In addi- 
tion, NOAA's National Marine Fisheries Service (NMFS) 
works with State and Federal regulators to either prevent the 
harvest ol toxin-contaminated fish and shellfish or to develop 
processes that effectively render the product safe to consume. 

NMFS laboratories are widely recognized for their exper- 
tise in research on processing procedures to inactivate and/or 
inhibit pathogenic microorganisms in seafood products. 
NMFS has worked closely with seafood processors and State 
and Federal agencies in develop and implement improved 
procedures. Recent cooperation among NMFS, the FDA, and 
industry has produced Good Manufacturing Practices ((.\ll'i 
guidelines lor the smoked fish industry. 

Within its current voluntary seafood inspection program, 
NOAA has begun to offer an inspection sen ice based on 1 [az- 
.11 d \nalysis Critical Control Point (1 LACCP) principles on .1 
fee-for-service basis, firms participating in the program iden- 
til\ critical points in their operations, establish controls at 



each of the points, and monitor these areas to prevent prob- 
lems before they arise. Label approval, recordkeeping, and ana- 
lytical testing are included in NMFS HACCP-based program 
requirements. In addition, each facility/site in the program 
must have an employee, certified by NMFS, trained in 
I I \CCP principles. Benefits to participants include increased 
controls through a more scientific approach, use of established 
inspection marks, and enhanced consumer confidence. 

In support of risk assessment activities, NMFS has begun to 
establish a database on seafood contaminants, which will be 
accessible by other Federal and State agencies. NMFS has also 
funded a study to develop models for conducting seafood con- 
sumption surveys. Pilot studies of the consumption models are 
scheduled to be completed in 1993. 



Department of 
Defense (dod) 



The Department of Defense health promotion program, as 
defined in the DoD Directive 1010.10, has been in place since 
1986. This program focuses on six key areas: smoking preven- 
tion and cessation, physical fitness, nutrition, stress manage- 
ment, alcohol and other drug abuse prevention, and early 
identification of hypertension. In 1991, a needs assessment re- 
sulted in the selection of 181 of the Healthy People 2000: Na- 
tional Health Promotion and Disease Prevention Objectives for use 
by the Armed Services. Further refinement of the objectives 
into a subset of 45 gave the Armed Services specific guidance 
regarding the priorities of the DoD. 



DoD Prevention Highlights 

Women's Health Issues Policy Initiative. A 1992 Women's 
Health Issues Policy initiative addressed several health main- 
tenance issues. DoD offers annual health examinations, which 
include, but are not limited to, Papanicolaou smear, pelvic ex- 
amination, breast examination, blood pressure measurement, 
family planning, and contraceptive counseling for all women 
beneficiaries. DoD also requires a baseline mammogram at 
the age of 40 for all active duty women and offers this service 
to all other women beneficiaries. 

Cancer Prevention. A DoD and American Cancer Societj 
joint venture expanded cancer control programs and services to 
European installations. Volunteer-led, service-specific organi- 
zations deliver services and recruit, train, and maintain volun- 
teers. The primary focus has been tobacco control programs. 
Periodic evaluations identify problems, sm.ce-.scv. and ongoing 
needs. The demonstrated benefits to the community include 
the availability ol resources for public and professional educa- 
tion, nutrition education, and youth programs. Over the next 2 
years, plans are to expand this program to Pacific installation'.. 

The 1992 Worldwide Survey of Military Personnel ol 

Substance Abuse and Health Behaviors Among Military 
Personnel, ["his survej provided comprehensive .^nA detailed 
estimates ol the prevalence ot the use ol drugs, alcohol, and 



Agency Innovations 



tobacco among active duty military personnel. The study also 
examined the prevalence of health behaviors, knowledge and 
belief about AIDS, medical costs associated with heavy alcohol 
use and heavy smoking, and the effects ot Operations Desert 
Shield and Desert Storm on substance use. These findings in- 
dicated that the military has made steady and notable progress 
in combating smoking and in reducing drug and alcohol-re- 
lated problems. The findings also suggest that military per- 
sonnel were highly motivated to make changes in behavior 
that were designed to improve their health. 



Department of 
Education (doe) 



The largest Federal prevention program of the Department 
of Education is the Drug- Free Schools and Communities Act 
(DFSCA). DFSCA supports school- and community-based al- 
cohol, tobacco, and other drug prevention programs. Educa- 
tion is actively involved in disseminating information on im- 
plementing and evaluating prevention programs, identifying 
and disseminating information on successful prevention pro- 
grams, and administering a variety of formula and discre- 
tionary grant programs. Grant recipients include State and 
local educational agencies, other State and local agencies, in- 
stitutions of higher education, and community organizations. 
Other health promotion initiatives include spinal cord injury 
prevention programs, services to infants and toddlers with dis- 
abilities, dropout prevention programs, and comprehensive 
school health education programs. 



DoE Prevention Highlights 

Publications. The Department of Education has dissemi- 
nated several resources for school personnel and parents on 
preventing alcohol and other drug use by school-age children 
and youth, including: 

Learning To Live Drug Free: A Curriculum Model for Pre- 
vention is a classroom-based drug prevention curriculum 
model based on the premise that most young people do 
not use drugs. Its primary purpose is to enhance the de- 
velopment of life skills that keep children and youth from 
using alcohol and other drugs. The model provides the 
basic materials for starting or expanding a school-based 
drug education program for kindergarten through grade 
12. These materials include information about alcohol, 
tobacco, and other drugs; information for teachers on 
child growth and development; sample lesson plans and 
activities; and suggestions for involving parents and the 
community in drug prevention. The curriculum model 
has been distributed to every school district in the Na- 
tion, as well as to many private schools and to schools op- 
erated by and for the Bureau of Indian Affairs. 

Growing Up Drug Free: A Parent's Guide to Prevention was 
developed to help families take an active role in drug pre- 
vention. Drawing on the advice of experts in drug pre- 



vention and in child development, the handbook outlines 
what children at four key stages of development should 
know about drugs and suggests family activities to rein- 
force children's motivation not to use alcohol and other 
drugs. Nearly 23 million copies of the handbook, includ- 
ing a Spanish-language edition, have been requested. 

Schools Without Drugs provides assistance to schools and 
communities in developing a comprehensive program to 
prevent drug use. Based on the best available research, it 
emphasizes a plan for partnership among parents, stu- 
dents, communities, and schools to reduce and prevent il- 
legal drug use. Originally published in 1986, the hand- 
book has been revised twice to include current 
information on alcohol, tobacco, and steroids. Over 4 
million copies, including a Spanish language edition, have 
been distributed. 

Success Stories From Drug-Free Schools: A Guide for Educa- 
tors, Parents and Policymakers provides practical informa- 
tion on designing and implementing effective prevention 
programs. Real-life examples that worked to reduce drug 
use and violence are included from schools honored in 
the Drug-Free Schools Recognition Program (see 
below). 

The Challenge is a quarterly newsletter containing lesson 
plans for classroom use, information on alcohol, tobacco, 
and other drugs, current research on prevention, promis- 
ing prevention techniques, and sources of further infor- 
mation for teachers. 

In addition, DoE is collaborating with DHHS on a project 
to develop training materials for preschool and elementary 
school teachers and other school personnel who work with 
drug-exposed children in educational settings. Materials be- 
came available in 1993. 

Drug Prevention Programs for America's Schools and 
Colleges. The Drug-Free School Recognition Program hon- 
ors schools that prevent or substantially reduce student alco- 
hol, tobacco, and other drug use. These schools exemplify the 
level of community and school commitment required to make 
the Nation's schools drug-free. In school year 1991-92, the 
fifth year of the program, 79 public and private schools were 
selected for recognition of their achievements. 

More than 1,300 colleges and universities participate in the 
Network of Colleges and Universities Committed To Elimi- 
nating Alcohol and Drug Abuse. Initial networking efforts fo- 
cused on 4-year residential colleges so that information on 
comparable problems could be shared; however, the focus has 
expanded to address the concerns of the 2 -year student and 
the commuter population. 

Drug Prevention Grant Programs. The DFSCA State and 
Local Grants Program allocates funds to State education agen- 
cies (SEAs) and governors' offices for alcohol and other drug 
use prevention, early intervention, and rehabilitation referral 
programs; parent and community involvement activities; and 
services for youth at high risk for alcohol and other drug use. 

The DFSCA Regional Centers Program supports five cen- 
ters that provide training and technical assistance to State and 



reyfr 



Prevention '93/'94: Federal Programs and Progress 



tf^ 



local education agencies and institutions of higher education. 
Activities include school-team training, technical assistance 
for strengthening programs through coordination of services, 
developing training programs in prevention for education per- 
sonnel, and evaluating and disseminating information on ef- 
fective prevention programs and strategies. 

The Federal Activities Grants Program supports the devel- 
opment and implementation, dissemination, and evaluation of 
educational strategies and programs for drug and alcohol use 
education and prevention. The program priority in FY 1992 
and FY 1993 continued to be preventing alcohol use by K-12 
students, particularly high-risk youth. 

DFSCA Emergency Grants were awarded in FY 1992 to 83 
school districts that demonstrated a significant need for addi- 
tional assistance in preventing and reducing alcohol and other 
drug use and abuse in their schools and communities. Districts 
compete for funding to support a comprehensive range of ser- 
vices, including educational programs, after-school programs, 
programs for parents and other community outreach efforts, 
and alternative programs for students with a history of drug 
abuse or others who are difficult to reach in the regular school 
setting. 

The School Personnel Training Grants Program provides 
assistance to States, school districts, and institutions of higher 
education for training elementary and secondary school teach- 
ers, administrators, and other school personnel in drug and al- 
cohol abuse education and prevention. In FY 1992, training 
for counselors, social workers, psychologists, and nurses serv- 
ing school-aged children and youth was also provided through 
a program set-aside. 

Demonstration Grants to Institutions of Higher Education 
support the development of elementary and secondary school 
prevention programs. In FY 1992, program priorities were to 
demonstrate the effectiveness of drug and alcohol prevention 
strategies and to involve faculty of institutions of higher learn- 
ing, elementary and secondary teachers, and community rep- 
resentatives in the practical application of research findings in 
drug and alcohol abuse education and prevention. 

Innovative Alcohol Abuse Education Programs are designed 
to benefit children in grades 5 through 8 and to focus on the 
effects of familial alcoholism on children of alcoholics. Train- 
ing materials were developed in FY 1991. Training for middle 
school personnel on the use of these materials will be contin- 
ued regionally through March 1994. 

Drug Prevention Programs for Higher Education supports 
campus-based programs for students enrolled in colleges and 
universities. Administered by the Office of Postsecondary Ed- 
ucation, this program awards grants to develop, implement, 
and evaluate alcohol and other drug prevention programs, and 
to disseminate information on successful practices and strate- 
gies in post-secondary settings. 

Program F. valuation Activities. The Office of Policy and 
Planning, in conjunction with the Office of Elementary and 
Secondary Education, conducts evaluation studies of DFSCA 
prevention programs. Currently, Education is involved in the 

2nd year of data collection in a longitudinal study of student 
outcomes ol school-based drug prevention programs; findings 
will be available in late 1995. An assessment of training and 
technical assistance services provided by the Regional Centers 
and a survey ol institutions of higher education alcohol ami 
ither drug prevention programs and policies are also being 



conducted. Education has also been working to identify suc- 
cessful and/or innovative prevention practices and strategies in 
schools and communities across the Nation. 

National Institute on Disability and Rehabilitation Re- 
search (NIDRR). X1DRR supports research on the nature of 
disabilities and the interventions that can prevent disabilities 
and improve rehabilitation outcomes. NIDRR supports 13 
Model Spinal Cord Injury Systems and 4 Model Brain Injun- 
Systems that include education programs directed at high 
school youth, as well as younger children. NIDRR supports 
projects to develop curricula and training materials for spinal 
cord injury prevention. NIDRR also supports a universitv- 
based Research and Training Center on Childhood Trauma 
that utilizes a national pediatric trauma data base and registry 
and focuses on the prevention of childhood trauma through 
accidents and intentional injuries. In one of several intera- 
gency efforts, NIDRR cooperated with the National Commis- 
sion to Prevent Infant Mortality, whose goal was to bring to- 
gether health and educational organizations and agencies to 
prepare a joint strategic plan to enhance the full learning po- 
tential of all children. 

Office of Special Education Programs (OSEP). OSEP ad- 
ministers Part H of the Individuals with Disabilities Education 
Act, which authorizes the Grants for Infants and Families Pro- 
gram. This program provides support to States to plan, de- 
velop, and implement a comprehensive multidisciplinarv 
statewide system of early intervention services for children 
(a^'e 0-2) with disabilities and their families. Eligible children 
are those infants and toddlers experiencing developmental de- 
lays (as diagnosed in the following areas: cognitive develop- 
ment, physical development, language and speech develop- 
ment, psychosocial development) or who have a diagnosed 
physical or mental condition that has a high probability of re- 
sulting in developmental delay. Once fully implemented, this 
program should significantly improve access to early interven- 
tion services, increase the scope and quality of the services 
available, and improve the cost-effectiveness of providing ser- 
vices to infants and toddlers with disabilities. .All participating 
States provided full services in FY 1993. 

Five-year grants for two early childhood research institutes 
were awarded in FY 1991. The Earl) Childhood Research In- 
stitute on Substance Abuse conducts longitudinal studies on 
children prenatally exposed to alcohol ami other drugs. The 
Institute also develops, tests, and disseminates collaborative 
interventions for very young children who are at risk tor de- 
velopmental delays, or are developmental^ delayed or dis- 
abled. The National Early Childhood Technical Assistance 
System trains early intervention personnel and disseminates 
information on service delivery models and best practices. 

The School Dropout Demonstration Assistance Program. 

This program has been funded since 1988 tor the purpose ol 
increasing the number ol students who complete elemental - ) 
and secondar) education. Research strongl) suggests the need 
for a comprehensive approach to dropout prevention reentrv 
that not only addresses the problems and needs ol students 
who are at risk or have already dropped out ol school, hut in- 
cludes the restructuring and reform of the operation ol ele- 
mentary and middle schools, .is well as the high schools. Find- 
ings from a national evaluation ol projects funded in 1' l 1988 



Agency Innovations 



will become available in 1993. An evaluation of projects 
funded in FY 1991 is in progress. 

The Comprehensive School Health Education Program. 

This program is supported by the Fund for Innovation in Ed- 
ucation and provides grants to States, school districts, institu- 
tions of higher education, and other public and private entities 
to improve health education for elementary and secondary 
students. The program currently supports innovative projects 
of national significance. Recent program priorities include 
demonstrating and evaluating promising approaches to com- 
prehensive school health education, providing the training 
needed to implement such programs, and disseminating infor- 
mation about effective programs to States and communities. 



Department of 
Energy (doe) 



With approximately 200,000 Federal and private contractor 
employees engaged in the development and use of nuclear en- 
ergy and other energy sources and in the cleanup of the U.S. 
weapons facilities, health protection has become a primary 
concern for DOE. A milestone in DOE's emphasis on worker 
health protection came in 1990 when DOE established an Of- 
fice of Health. This Office is the DOE focal point for em- 
ployee health protection. It is responsible for identifying the 
potential harmful effects of DOE activities on human health 
and for promulgating and initiating programs and policies that 
will effectively prevent or mitigate these effects. 



DOE Prevention Highlights 

Environmental Health. Active cleanup of DOE sites has 
started recently. DOE's Office of Environmental Restoration 
and Waste Management, the operational program responsible 
for cleanup activities, estimates that the cleanup of 40 years of 
nuclear weapons manufacture will take over 30 years and cost 
over $100 billion. Approximately $1.4 billion was spent on 
cleanup actions in FY 1992. A recent report from the United 
States Congress, Office of Technology Assessment, entitled 
"Hazards Ahead: Managing Cleanup Worker Health and 
Safety at the Nuclear Weapons Complex," discussed the un- 
certainties associated with characterizing the contamination of 
many of the DOE weapons sites and the difficulties of design- 
ing appropriate worker health and safety programs. In partial 
response to this report, the DOE Office of Health is develop- 
ing enhanced medical guidelines for the surveillance of haz- 
ardous waste workers. The cleanup activities are closely coor- 
dinated with DHHS agencies, such as the Agency for Toxic 
Substances and Disease Registiy, and with other national and 
international organizations. 

Cancer. DOE funds a number of research programs for de- 
veloping a better understanding of the etiology of cancer. Per- 
haps the most significant program is the Human Genome 
Program. In FY 1992, DOE spent approximately $130 million 
on genome and other mechanistic biological research. DOE 



also supports a number of major foreign research programs 
aimed at developing a better understanding of the effects of 
radiation. The most significant DOE-supported foreign re- 
search activity is the Radiation Effects Research Foundation 
(RERF) in Japan, which is jointly supported by the U.S. and 
Japanese Governments. RERF studies the effects of the 
atomic bomb blasts in Hiroshima and Nagasaki, and RERF 
data have been used worldwide as a reference for setting base- 
line radiation protection standards. Other significant foreign 
radiation research projects include the Marshall Islands pro- 
gram, the Palamores program in Spain, and Health and Envi- 
ronmental programs in the former Soviet Union. The studies 
in the former Soviet Union are done in cooperation with 
other Federal agencies. 

Occupational Safety and Health. DOE launched a new en- 
hanced occupational health program in 1992 with the issuance 
of DOE Order 5480.8A. This order requires 42 DOE con- 
tractor sites to provide their employees with expanded health 
examinations and tests to detect occupational illness or injury 
and to prevent disease or injury. The objectives of the DOE 
occupational medical program are to assist contractor man- 
agement in protecting employees from health hazards in their 
work environment; assure the early detection, treatment, and 
rehabilitation of employees who are ill, injured, or otherwise 
impaired; and use preventive measures toward the mainte- 
nance of the optimal physical and mental health of employees 
through health promotion and education. Numerous initia- 
tives have been started to increase individual employee's 
awareness about health issues. 

Surveillance and Data Systems. A major goal of DOE is to 
develop the capability to track the health status of its entire 
workforce. The need for employee monitoring gained con- 
gressional support in 1992 with the passage of the National 
Defense Authorization Act for FY 1993. This act mandates 
that DOE establish a medical monitoring and testing system 
for its employees who have had significant exposure to haz- 
ards. DOE anticipated the requirements of the act by initiat- 
ing in FY 1992 the development of a large medical surveil- 
lance computer network that will include radiological and 
industrial hygiene exposure information, demographic data, 
and clinical information. The system is being designed to 
allow DOE to take a proactive preventive approach to em- 
ployee health protection. In 1993 DOE defined die minimum 
medical data set for the system as well as the requirements for 
the hardware and software. In 1994 the system will be imple- 
mented at four pilot sites. The medical surveillance require- 
ments are being developed by the DOE Office of Health with 
input from the Department of Health and Human Services, 
the Department of Labor, the National Academy of Sciences, 
and other organizations. 

Educational and Community Based Programs. DOE sup- 
ports a number of initiatives aimed at making the public more 
aware of the effects of energy use and development. For exam- 
ple, DOE has initiated the National Science Bowl to promote 
science education nationwide for high school students. DOE 
provides fellowships for graduate students in industrial hy- 
giene and health physics. DOE also supports a number of 
community or state-level activities to promote a better under- 
standing of the potential health impacts of specific DOE oper- 



dal) 



Prevention '93/'94: Federal Programs and Progress 



ations in given States. In 1993 DOE will sponsor health agree- 
ments with seven States. In addition, each year DOE sponsors 
a large number of health-related conferences or symposia, 
media presentations, and scientific studies resulting in peer- 
reviewed publications. 

Department of 
Housing and Urban 
Development (hud) 

The provision of decent, safe, and sanitary housing implies 
a commitment to the health and safety of all program recipi- 
ents. Implicit in the Department of Housing and Urban De- 
velopment's programs is the goal of preventing illness and in- 
jury among program recipients. 

HUD Prevention Highlights 

Lead-Based Paint Hazards Removal. Pursuant to several 
statutory mandates, HUD is making a major effort to reduce 
and eventually eliminate lead-based paint hazards from all 
public and Indian housing. All such housing must be inspected 
for the presence of lead-based paint by December 1994; any 
lead-based paint must be abated when the housing is reno- 
vated. To reduce lead hazards prior to renovation, HUD 
strongly encourages housing authorities to conduct risk as- 
sessments and carry out interim controls. Over $100 million is 
being spent annually on inspection, abatement, risk assess- 
ment, and interim controls in public and Indian housing. 

Public and Indian housing, however, comprise only about 1 
percent of the total family housing stock in the United States 
that was built before the 1978 ban on lead-based paint. Pur- 
suant to Title X of the Housing and Community Develop- 
ment Act of 1992 and the 1992 and the 1993 Appropriations 
Acts, HUD is administering a program of grants to States and 
localities for lead-based paint hazard reduction in private 
housing. Approximately $47.7 million in FY 1992 and $90 
million in FY 1993 were competitively awarded. 

HUD is rewriting the Interim Guidelines for Hazard Iden- 
tification and Abatement to apply to all federally supported 
hazard reduction work. These guidelines recommend techni- 
cal protocols, practices, and procedures on testing, abatement, 
worker protection, cleanup and disposal of lead-based paint in 
residential structures. HLD is also changing its regulations 
pertaining to lead-based paint hazard reduction in federally 
assisted housing and federally owned housing, and HUD has 
revised the lead-based paint notification to purchasers and res- 
idents of all 1 Il'D-associated housing. 1 IL'D coordinates with 
the EPA, CDC, and other agencies through the Interagency 
Lead-Based Paint Task Force. Several agencies are supporting 
the Lead Hotline, l-800-LEAD FYI, which provides public 
information and serves as a national clearinghouse. 

Radon Contamination in Housing. The 1988 McKinnej 
I lomeless Assistance Amendments Act added ration to the po- 
tential environmental health hazards requiring action by 



HUD. This act called for a policy report dealing with radon 
contamination in HUD-owned and subsidized housing, pri- 
marily multifamily rental housing for low and moderate in- 
come people. The report was delivered to HLTJ in the spring 
of 1991. HUD has also cooperated with radon testing pro- 
grams conducted by the Indian Health Service over the past 
several years in some of its Indian housing stock. Beginning in 
1990, several Indian housing authorities requested and re- 
ceived funds for radon testing and mitigation. HL T D has en- 
tered into an interagency agreement with EPA to test and mit- 
igate radon in HUD-owned multifamily buildings in high 
radon areas. 

Housing and Community Development Assistance Pro- 
grams. Federal manufactured home construction and safety 
standards administered by HLTJ emphasize several health is- 
sues. Proposed amendments to these standards relative to in- 
door air quality address problems associated with formalde- 
hyde emissions and call for improvements in ventilation. 
Health notices on formaldehyde emissions are required to be 
placed on a temporary basis in the kitchen of each manufac- 
tured home. The notice can only be removed after the sale is 
final. Minimum property standards for housing include design 
considerations for builders, developers, and public officials to 
reduce potential risk to public health from both manmade and 
natural hazards and irritations such as toxic dumps, power 
lines, and unscreened drainage canals. These standards also 
apply to nursing homes and group care facilities insured by 
HLTD and the siting of housing and other facilities using 
Community Development Block Grant funds. All States and 
local governments that are recipients of Community Develop- 
ment Block Grant funds are required to conduct an environ- 
mental assessment taking into account potential health and 
safety hazards. 

Drug Elimination Program. HUD has established an Office 
for Drug-Free Neighborhoods to promote a safer and health- 
ier living environment through the elimination of drugs from 
public housing developments. The Office works with public 
housing officials and residents to leverage resources and de- 
velop creative solutions to solve the drug problem. The Office 
encourages housing authorities to develop housing manage- 
ment, enforcement, and prevention strategies as part of a 
comprehensive effort to decrease and eventually eliminate the 
drug problem in public housing. The Public Housing Drug 
Elimination Grant Program provides funds to public housing 
authorities to help them develop strategies to tight drugs in 
their area. The Office also offers a technical assistance pro- 
gram providing short-term consultation to help troubled 
housing authorities better address the drug problem within 
their communities. One-on-one assistance and technical re- 
source materials are offered through the Office's Drug Infor- 
mation and Strategy Clearinghouse. 

Child Clare. HUD's program of child care assistance pro- 
motes the goal of early intervention for low -income children 
entering school. HL'l) has supported several innovative child 
care programs in public .wn\ Indian housing and helped hind 
expansion of DHHS's Head Start Bureau's programs. Hiese 
efforts provide lull day wraparound child care tor children 
who may be younger or older than the 3- to 5-year-olds 
served by traditional I lead Stan programs. 



Agency Innovations 



Assistance for the Homeless. Under IIUD's Stewart B. 
McKinney Act Program, States, local governments, and non- 
profit organizations receive funds to assist them in providing 
housing and supportive services for homeless persons. In- 
cluded among the supportive services are those that maintain 
health, such as food, nutrition, counseling, referrals for health 
care, and alcohol and substance abuse counseling. HUD also 
works closely with DHHS on programs for the homeless 
mentally ill population. 

Public Housing Health Services. HUD and DHHS have sev- 
eral programs to provide primary health care to residents of 
public housing. One collaboration provides grants for a variety 
of health, education, and health counseling sendees for adults 
and children. HUD works with DHHS to assure that the 
Healthy Start program meets its goal of reducing infant mortal- 
ity by SO percent over 5 years, and also works with other agen- 
cies to improve access to immunization services for children. 



Department of the 
Interior (doi) 



As the Nation's principle resource and land conservation 
agency, DOI guides the efforts of nine bureaus or services, in- 
cluding the National Park Service (NPS), Fish and Wildlife 
Service (FWS), Bureau of Mines (BOM), Bureau of Reclama- 
tion (BOR), U.S. Geological Survey (USGS), Bureau of Land 
Management (BLM), Bureau of Indian Affairs (BIA), Minerals 
Management Sen-ice (MMS), and Office of Surface Alining 
and Enforcement (OSAI). Within DOI, initiatives to enhance 
employee and visitor safety and health have been developed. 



DOI Prevention Highlights 

Radon Evaluation and Mitigation. DOI organized a major 
radon evaluation and mitigation effort from 1989 to 1992. A 
publication on radon measurement and mitigation was re- 
leased. In 1993 and 1994, program data are being analyzed 
and updated and many of the mitigation efforts are being eval- 
uated for effectiveness, including an innovative mitigation 
program for reduction of radon in fish hatcheries. 

Visitor and Boating Safety. Programs for the reduction of 
visitor injuries in or on DOI facilities and Federal lands have 
developed. Visitor safety training and accident investigation 
initiatives were consolidated into a department-wide effort. A 
boating safety policy was published in 1992 that addresses em- 
ployee-safety programs for the DOI work force involved in 
duty-related boating activities and visitor safety. A major in- 
structor training effort is underway in 1993 and 1994. It is ex- 
pected to train over 60 boating safety instructors who will in 
turn provide education programs to thousands of DOI facility 
employees and visitors. 

Employee Medical Health and Assistance Programs. Dur- 
ing 1992, DOI improved Occupational Health and Employee 
Assistance Medical Programs by establishing Interior Medical 



Health Units in Albuquerque and Santa Fe, New Mexico; 
Denver, Colorado; Pittsburgh, Pennsylvania; and Washing- 
ton, DC. Following a period of evaluation on the cost of med- 
ical treatment, medical surveillance, and employee medical as- 
sistance for the existing medical health units, additional units 
are expected to be established at other field locations in 1993 
and 1994. 

Hazardous and Toxic Material/Waste Initiatives. A major 
DOI initiative is currently redefining the acquisition, use, and 
disposal of hazardous and toxic materials. This program is train- 
ing DOI employees and supervisors to substitute less hazardous 
or nonhazardous material in routine work. Efforts are being 
made to more effectively handle and manage the waste resulting 
from DOI operations, and to evaluate and remediate areas con- 
taminated by past inadequate waste handling practices. 



Department of 
Justice (doj) 



Office of Justice Programs (ojp) 

The Office of Justice Programs in the Department of Jus- 
tice (DOJ) provides funding, technical assistance, and training 
to State and local units of government and private nonprofit 
organizations for crime prevention and control, drug abuse 
prevention, prevention of family violence, including elder 
abuse, child physical and sexual abuse, and disease prevention 
as it relates to the criminal justice system. 

OJP is comprised of five major bureaus or offices, each of 
which, among other things, sponsors prevention-related activ- 
ities. These are the Bureau of Justice Assistance (BJA), the Bu- 
reau of Justice Statistics (BJS), the National Institute of Justice 
(NIJ), the Office of Juvenile Justice and Delinquency Preven- 
tion (OJJDP), and the Office for Victims of Crime (OVC). 

OJP priorities include preventing and controlling violence 
and drug trafficking by gangs, crime and drug abuse preven- 
tion and education, community-based programs to combat 
crime and drug use, and assistance for crime victims, including 
physically and sexually abused children and elder abuse. 

OJP Prevention Highlights 

Comprehensive Law Enforcement and Community Revi- 
talization Strategy. Operation Weed and Seed is a major ef- 
fort of DOJ. Begun in late FY 1991, the initiative is a commu- 
nity-based, comprehensive, multi-agency approach to 
combatting violent crime, drug use and gang activity in high- 
crime neighborhoods. The goal is to "weed out" crime from 
targeted neighborhoods and then to "seed" the targeted sites 
with a wide range of crime and drug prevention programs and 
human service agency resources to prevent crime from reoc- 
curring. FY 1993 funds continued phase II of the Weed and 
Seed strategy at 20 demonstration sites. Training and techni- 
cal assistance and victim outreach sendees, developed under 
the discretionary grant programs were also made available to 
the sites. In FY 1993, many cities and communities took steps 



® 



Prevention '93/'94: Federal Programs and Progress 



^^ 



to implement the Weed and Seed strategy with existing re- 
sources. Interagency agreements with various Federal agencies 
support core components of Weed and Seed, including Safe 
Haven Multi-Human Service Centers, Community Policing 
in public housing, and neighborhood and resident mobiliza- 
tion as well as economic revitalization activities and establish- 
ment of comprehensive recreation programs. 

Preventing and Controlling Gang Violence. Information 
gathered from an OJP field study on gangs and gang violence 
has been used to design a plan of action for preventing young 
people from becoming involved in gang activity; for salvaging 
peripheral gang members; for identifying, arresting, and pros- 
ecuting hard-core gang members; and for assisting the victims 
of gang-related crimes and their families. BJA's Comprehen- 
sive Gang Initiative involves a national assessment of gang 
drug trafficking and related violent criminal activity and de- 
velopment of local prevention and control measures. 

Under a grant from OJJDP, the Boys and Girls Clubs of 
America are implementing a program called Targeted Out- 
reach with a Prevention and Intervention Component. This 
program currently supports gang prevention and intervention 
programs in 33 cities. Twenty-four additional cities began 
programs. 

6jJDP, along with HUD in FY 1993, also funded a program 
to establish Boys and Girls Clubs in public housing in an effort 
to prevent gang violence and drug abuse. OJJDP also supports 
a Gang Policy Training Program, which provides intensive 
training to communities to assist them with the assessment of 
their gang problems and the development of action plans to in- 
tervene with and prevent gang violence. In addition, OJJDP 
funds the National Gang Clearinghouse, which serves as a re- 
source center for gang related materials and information. 

In FY 1993, NIT sponsored an evaluation of three compre- 
hensive gang prevention and intervention programs. A study 
on the acquisition and use of firearms by incarcerated juve- 
niles and inner-city high school students, in five sites, ad- 
dresses the relationship between gun ownership, violence, 
gang membership, and drug trafficking and abuse. 

Drug Demand Reduction Activities. OJP supports the 
Drug Abuse Resistance Education (DARE) program, which 
teaches children to resist peer pressure to experiment with 
drug use. BJA funds five regional centers that train State and 
local law enforcement to be DARE instructors. In FY 1992, 
I) \KF training was expanded to include drug use prevention 
training for parents. 

Through BJA and OJJDP, OJP is working with Columbia 
University's Center on Addiction and Substance Abuse, for- 
merly of New York University, to help six cities rescue their 
high-risk pre-adolescents from the interrelated threats of 
poverty and drugs through the Strategic Intervention for 
1 ligh-Risk Youth Program. This multiservice, neighborhood- 
based program coordinates resources by program participants 
(e.g., schools, child welfare system, local, public ami private 
service providers, and all components of the criminal and ju- 
venile justice system). BJA is working with Operation PAR 
(Parental Awareness and Responsibility ) to provide drug abuse 
prevention training and technical assistance to Weed anil Seed 
project sites. 

OJP supports the National Citizens' Crime Prevention 
Campaign of cost-effective prevention initiatives. McGruff 



the Crime Dog and the "Take a Bite Out of Crime" slogan 
leveraged in 1992 S60.3 million in donated air and space time 
for public sendee educational messages that targeted English- 
and Spanish-speaking populations. Other accomplishments 
included the free distribution of more than 425,000 crime, vi- 
olence, and drug prevention publications; the training of hun- 
dreds of law enforcement representatives, other service 
providers, and communities; and the coordination of the 136- 
member Crime Prevention Coalition. 

OJJDP supports several programs to prevent drug and alco- 
hol abuse and reduce the demand for illegal drugs. The Wings 
of Hope program, run by the Southern Christian Leadership 
Conference, mobilizes inner-city communities in an effort to 
prevent drug and alcohol abuse and provide services to fami- 
lies. Through the National Center for Neighborhood Enter- 
prise, OJJDP supports small community-based agencies that 
are involved in drug prevention and treatment programs. 
OJJDP is also working in a collaborative effort between the 
National Highway Traffic Safety Administration, the Depart- 
ment of Agriculture, and the National 4-H Club to develop 
the capacity of communities to plan comprehensive strategies 
to prevent drug abuse and to treat drug abusers. In addition, 
OJJDP and several Federal partners (Departments of Labor, 
Health and Human Services, and Commerce) support a na- 
tional dropout prevention effort developed and implemented 
by Cities in Schools. 

In 1993, NIJ completed an evaluation of BJA's national 
demonstration program on community responses to prevent- 
ing drug abuse. This evaluation studied grassroots programs 
in six sites and examined the effectiveness of various commu- 
nitj group approaches to preventing drug trafficking and 
abuse in their neighborhoods. 

Edward Byrne Memorial State and Local Law Enforce- 
ment Assistance Grants. BJA's formula grant program pro- 
vides each State and Territory with funds for drug control and 
criminal justice system improvement programs. States may use 
BJA formula grant funds for drug demand reduction education 
programs; community and neighborhood programs to reduce 
crimes against the elderly; crime prevention in rural areas; pro- 
grams to identify and treat adult and juvenile drug and alcohol- 
dependent offenders; and programs to improve the criminal 
and juvenile justice system's response to domestic violence. 

BJA also administers a discretionary grant program, which 
provides assistance to public, private, and private nonprofit or- 
ganizations for training, technical assistance, demonstration 
programs, and national scope programs related to drug en- 
forcement and criminal justice system improvement. 

National Crime Victimization Survey. BJS's National 
Crime Victimization Survey samples 50.000 households, com- 
prising more than 100.0(H) persons, who are interviewed about 
their experience as victims of crime. A new questionnaire has 
been implemented by BIS to improve the respondent's abilitv 
I'UA all crimes, especially in eases ol family violence anil rape. 

Research on Crime and Its Control. Nil is the primary 
Federal sponsor of research on crime, crime prevention and 
control, criminal behavior, and criminal justice technology. 
Current research and evaluations include studies of violence 
and drug use. use of community policing. .\nd innovations in 
corrections. 



Agency Innovations 



Juvenile Justice and Delinquency Prevention Grants. 

Through its discretionary grant program, OJJDP encourages 
State and local governments, private organizations, and indi- 
viduals to develop programs to prevent and control crimes by 
gangs, provide alternative education programs for troubled 
students, prevent school dropouts, develop community-wide 
strategies to prevent drug abuse, and prevent hate crimes. 
OJJDP also provides formula grants to States to prevent delin- 
quency and improve their juvenile justice systems. 

Missing and Exploited Children. OJJDP is responsible for 
coordinating the Federal response to the problem of missing 
and exploited children. OJJDP's landmark report, "Missing, 
Abducted, Runaway, and Thrownaway Children in America," 
produced the first scientifically derived estimates of a wide 
range of problems affecting children perceived as missing. In 
addition, OJJDP supports the National Center for Missing 
and Exploited Children, which helps locate and recover miss- 
ing children, and provides technical assistance to law enforce- 
ment, nonprofit organizations, and individuals regarding 
missing children and child sexual exploitation. OJJDP also 
supports the National Court-Appointed Special Advocates As- 
sociation, which provides training and technical assistance to 
State and local programs that recruit volunteers to advocate 
the best interests of abused and neglected children during ju- 
dicial proceedings. 

OVC supports the National Center for the Prosecution of 
Child Abuse, which assists State and local prosecutors han- 
dling child abuse cases. OVC also administers the Children's 
Justice Act Grant Program for Native Americans, which helps 
federally recognized Indian tribes to improve the investiga- 
tion, prosecution, and handling of child abuse cases in a way 
that lessens trauma to the child victims. 

Assistance to Crime Victims. OVC provides funding to the 
States to support victim compensation and assistance pro- 
grams and works to improve the Nation's response to victims 
of crime and their families. OVC supports programs to train 
State and local law enforcement officials how to better re- 
spond to domestic violence calls for assistance and how to im- 
prove their sensitivity in dealing with the victims of family vio- 
lence. OVC also provides training and technical assistance to 
corrections and probation officials to notify victims of the re- 
lease status of offenders, thereby offering crime victims infor- 
mation that could prevent a second victimization at the hands 
of the same offender. OJJDP supports a project designed to 
reduce victimization of teenagers. Teens in Action provides 
training and other assistance to encourage young people to 
become involved in crime and drug abuse prevention activities 
in their schools. Recently, the program was expanded to in- 
clude prevention programs for Native American teens, teens 
in rural areas, and those in juvenile institutions. 

Disease Prevention: Corrections. NIJ, in collaboration with 
CDC, has surveyed the Federal Bureau of Prisons, the 50 
State correctional systems, and 33 of the largest city and 
county jail systems in the United States on the impact of AIDS 
and tuberculosis on corrections. Also ongoing is a 3 -year re- 
search demonstration and evaluation project, in collaboration 
with the National Institute on Drug Abuse, to design, test, and 
evaluate the effectiveness of various HIV/MDS education 
strategies on arrestees held less than 48 hours in jail booking 



facilities and lockups. Data collected in the AIDS Education in 
Lockups and Booking Facilities Project will provide informa- 
tion on how to get arrestees into treatment and how to change 
health-related attitudes and behaviors. 

NIJ has recently launched a three-way Federal partnership 
with CDC and the Center for Substance Abuse Treatment 
(CSAT) at the Substance Abuse and Mental Health Services 
Administration to provide training and technical assistance for 
managing the treatment of offenders with substance abuse 
problems and infectious diseases in corrections. Also under- 
way is a study on the impact of infectious diseases on commu- 
nity corrections with a focus on the nexus between community 
corrections and public health in providing services for re- 
leasees with HIV or TB infections. 

Information Dissemination. The National Criminal Justice 
Reference Service (NCJRS) disseminates findings from OJP- 
supported programs and research. Public access to the more 
than 110,000 information entries in the NCJRS electronic 
data base can be utilized with the assistance of trained refer- 
ence specialists via toll-free phone lines. Registered users re- 
ceive publications issued by OJP agencies, including NIJ Jour- 
nal and the bimonthly NIJ Catalog to keep them abreast of 
new research, programs, and publications regarding crime, 
crime victims, and the criminal and juvenile justice systems. 

NCJRS also operates the BJA Clearinghouse, die Justice 
Statistics Clearinghouse, the Juvenile Justice Resource Center, 
the National Victims Resource Center, the MDS Clearing- 
house, and the Corrections Construction Information 
Exchange. All the NCJRS clearinghouses can be reached toll- 
free on 1-800-85 1-3420, or in the Washington, DC, metro- 
politan area on 301-251-5500. Additionally, BJS sponsors the 
Drugs and Crime Data Center and Clearinghouse, which can 
be reached toll-free on 1-800-666-3332. 



Department of 
Labor (dol) 



The Department of Labor conducts a number of preventive 
and rehabilitative health programs. The Mine Safety and 
Health Administration (MSHA) and the Occupational Safety 
and Health Administration (OSHA) develop health and safety 
standards to protect workers exposed to work-related hazards 
and take necessary enforcement steps to ensure compliance. 
They also provide information to employers and employees to 
enable them to be properly trained and to take appropriate 
precautions with regard to workplace hazards. These stan- 
dards deal with a wide variety of hazards such as lead and 
other chemical exposures. 

The Employment Standards Administration programs in- 
clude the issuance and enforcement of hazardous occupations 
orders for child labor, workers' compensation efforts to pin- 
point the major causes of disabilities (such as lower back prob- 
lems) and the rehabilitation and re-employment of injured 
workers, and assisting disabled people gain reasonable accom- 
modation (that ensures safety) in employment. The Employ- 
ment and Training Administration provides training opportu- 
nities for thousands of potential workers (e.g., through the Job 



^^ 



Prevention '93/'94: Federal Programs and Progress 



® 



Corps). This training increasingly includes components to aid 
potential workers to identify and deal with workplace hazards. 
The Job Corps also provides a variety of preventive health 
measurers to all of its participants. 



Occupational Safety and Health 
Administration (osha) 

OSHA strives to provide American workers with job envi- 
ronments as free as feasible from health and safety hazards. It 
develops safety and health standards; enforces these standards 
through worksite inspections with citations and penalties for 
violations; conducts training programs to increase the occupa- 
tional safety and health competency of OSHA personnel, em- 
ployers, and workers; and encourages active employer involve- 
ment in safety and health through free consultation for 
employers and a program for recognizing employers with es- 
pecially good safety and health records. It provides grants to 
States to operate their own occupational safety and health en- 
forcement programs, which must be at least as effective as the 
Federal program. It also helps Federal agencies provide safe 
and healthful conditions for their employees. 

OSHA Prevention Highlights 

Bloodborne Pathogens. OSHA conducts inspections to en- 
force its new bloodborne pathogens standard to ensure that 
employers provide employees with adequate protection from 
the hazards associated with occupational exposure to blood- 
borne pathogens such as HIV and hepatitis B. OSHA contin- 
ued its public outreach efforts by offering training courses and 
reference materials such as videotapes, booklets, and fact 
sheets to the medical and dental communities. 

Cumulative Trauma Disorders. OSHA assists employers in 
dealing with cumulative trauma disorders caused by repetitive 
motion. This includes ergonomics program management 
guidelines for the meatpacking industry; ergonomic training 
courses for Federal and State personnel and for representatives 
of the private sector; an Advance Notice of Proposed Rulemak- 
ing for an ergonomic safety and health management rule; and 
enforcement activities with the use of setdement agreements. 

Enforcement Improvements. OSHA directs enforcement re- 
sources to the most dangerous industries through its inspection 
targeting system. A national program aimed at reducing in- 
iurics, illnesses, and fatalities associated with chemical plant ex- 
plosions and fires was recently completed. OS] 1A enforces its 
chemical process safely management standard through physical 
inspections of plants, evaluation of documented workplans 
covering process hazard analysis, employee training, and emer- 
gency response procedures. Local emphasis programs focus 
enforcement efforts on hazardous industries in limited geo- 
graphic areas such as logging in New England, cotton dust in 
the Southeast, and sealood harvesting in the Northwest. 

OS] I A also continues to emphasize the deterrent effect of 
substantial penalties, particularly in egregious eases, and, 
where possible, seeks to negotiate corporate-wide settlement 
agreements so that hazards will be abated not only in the in- 
spected plant, but also in similar facilities in the corporation. 



These agreements have proved particularly useful in correct- 
ing ergonomics problems in meatpacking and other food-pro- 
cessing corporations. OSHA has recently improved its proce- 
dures for monitoring corporate-wide settlement agreements. 

Standard Setting. As one way of improving the standard 
setting process, OSHA is using negotiated rulemaking. Nego- 
tiated rulemaking is a procedure that allows the interested 
parties to identify the major issues, gauge their importance, 
gather the information necessary to resolve the issues, and de- 
velop a rule that is acceptable to the various interests. Re- 
cently, OSHA used the procedure to promulgate its final rule 
for methylene-dianiline. 

The agency issued final rules for confined spaces and work- 
place exposure to cadmium and an interim final rule for expo- 
sure to lead in the construction industry. The agencv antici- 
pates final actions on standards addressing 1,3 butadiene, 
respiratory protection, and glycol ethers. 

Assistance Programs and Outreach. OSrIA's cooperative 
efforts include programs for compliance assistance, employer 
recognition, and training. 

• Consultation. Through OSHA support, State consul- 
tants provide free assistance to employers in the identifi- 
cation and correction of hazards and the development of 
effective workplace safety and health plans. Approxi- 
mately 28,000 consultation visits are conducted annually. 

• Voluntary Protection Program. OSHA recognizes 
employers that have especially good safety and health 
programs. An estimated 135 worksites were included in 
this program. 

• Training. OSHA's Training Institute provides basic 
and advanced courses in job-related safety and health for 
more than 8,000 Federal, State, and private personnel 
annually. To extend die reach of the Institute, training 
centers at colleges and universities are under develop- 
ment. OSHA annually awards about SI. 5 million in 
grants to nonprofit organizations to provide safety and 
health training and education to employers and employ- 
ees in such areas as logging safety. 



Mine Safety and Health 
Administration (msha) 

MSHA helps to reduce deaths, injuries, and illnesses in 
mines. MSHA develops and enforces salctv and health rules, 
helps mine operators who have special compliance problems, 
and makes available technical, educational, and other types ol 
assistance. MSHA's responsibilities apply to all mining .md 
mineral processing operations in the United States, regardless 
ot si/e, number of employees, or method ot extraction. 

MSHA Prevention Highlights 

Job Safety Analysis. With the understanding that many 
workplace accidents occurring in the mining industry involve 
poor judgment, overfamiliarity, and inadequate supervision 
ami training. \1SI I \ encourages the use of Job S.ilclv Analy- 
sis, a proven accident prevention tool. Workers and supervi- 
sors jointly analyze each step ol a hazardous work assignment 



Agency Innovations 



to determine the safest way to complete the task. The process 
becomes an effective training module for new workers because 
they learn how to do a job in the safest possible way. 

Reduced Coal Dust Exposure. After issuing citations to 
over 500 mining companies in 1991 for tampering with sam- 
ples for measuring levels of coal dust at mine sites, MSHA 
formed a task force to study ways of improving the dust-sam- 
pling program and preventing this tvpe of abuse. 

Roof Evaluation — Accident Prevention. Falls of mine roof 
or side walls have been the leading cause ot fatal accidents in 
mining. In order to call attention to the high risk, MSHA en- 
courages the use of safety training, temporary roof supports, 
and technical information to increase awareness of the hazards 
of unsupported roof. Mine inspectors distribute audiovisual 
products such as posters, bumper stickers, hardhat stickers, 
and tape-recorded messages that call attention to the dangers 
of walking under an unsupported roof. 

Small Mines Initiative. To reduce the higher rate of fatalities 
that occur at small coal mine operations, MSHA utilizes a 
small mines training initiative that targets mines in four States 
that have historically accounted for the most mining fatali- 
ties — Kentucky, West Virginia, Pennsylvania, and Virginia. 
MSHA assigns training specialists whose sole responsibility is 
the improvement of health and safetv programs at the selected 
mine sites. 

Regulations and Standards. MSHA has recently completed 
two important rules to strengthen prevention efforts: 

• Ventilation. The standards for underground coal mine 
ventilation, which had not been updated for over 20 
years, were revised. For example, it provides for the vol- 
untary use of atmospheric monitoring systems as an al- 
ternative to certain air measurements and tests. The rule 
sets mandatory standards for ventilation plans. 

• Civil Penalties. Civil penalties were increased across 
the board. These changes are intended to induce greater 
overall mine operator compliance with MSHA's safety 
and health standards, thereby preventing miner injuries, 
illnesses, and deaths. 



Department of State 



Office of Medical Services 

The Office of Medical Services (MED) in the Depart- 
ment of State provides a wide variety of preventive health 
and primary care medical services to well over 25,000 em- 
ployees and family dependents within the foreign affairs 
community. MED provides comprehensive occupational 
health services for foreign affairs families by providing med- 
ical clearance examinations, treatment for work related in- 
juries and illnesses, provision of primary care when not 
available locally, and referral of patients to private physi- 
cians for ongoing medical care (where available). Many pri- 
mary and secondary prevention programs are integrated 
into existing medical services. 



A comprehensive periodic medical clearance examination is 
required of all foreign affairs employees and family members 
to obtain medical benefits provided by MED. The examina- 
tion includes a history and physical examination, selected lab- 
oratory studies, tuberculosis screening, oral health screening, 
and age-related screening examinations (such as mammogra- 
phy and sigmoidoscopy). The examination is customized to fit 
the unique health risks the foreign affairs community faces 
overseas, as well as risks that are related to sex or age. Follow- 
ing each examination, a nurse or nurse practitioner reviews 
each patient's examination results to reinforce health educa- 
tion messages provided by the examining physicians. Once the 
employee has an assignment to a specific post, relevant immu- 
nizations or chemoprophylaxis are provided. In addition, 
nurses review environmental conditions that may adversely af- 
fect the health of the employee or family at the new post. 

Overseas, MED provides services depending upon the 
availability of health care locally. Where outside health care 
services are minimal, MED, or locally hired health care 
providers, provide direct primary care as well as a broad range 
of preventive health care services. Where health care locally is 
adequate, the focus of health care provided by MED health 
care providers shifts toward preventive health and health pro- 
motion activities. MED also provides a wide variety of mental 
health services through five major programs: alcohol and drug 
awareness program; employee consultation service; psychol- 
ogy; overseas mental health program; and mental health grant 
program. Many mental health services are preventive in na- 
ture, exemplified in training seminars that address cross-cul- 
tural adaptation, stress-reduction techniques, raising children 
abroad, self-help for depression, and alcohol awareness. 

The overseas mental health program is provided through 10 
psychiatrists posted abroad. In addition to providing direct pa- 
tient care, the psychiatrists hold community education pro- 
grams, support the mental health grant program through con- 
sultations and presentations, and are actively involved in crises 
intervention work. 

Environmental Health and Preventive Medicine (EHPM) 
Program. EHPM formulates policy, as well as provides con- 
sultation services in order to reduce the adverse impact of air 
pollution, food contamination, water quality and treatment op- 
tions, radon, asbestos, childhood lead poisoning, health effects 
from ionizing and non-ionizing radiation, and pesticide use. 
EHPM is also involved in epidemiological investigations of en- 
vironmental hazards such as exposure monitoring of embassy 
personnel in Kuwait during the oil fires or in Mexico City fol- 
lowing the outbreak of lead poisoning from ceramicware. 

Health promotion/education programs are offered at over- 
seas posts on MDS, nutrition, exercise, smoking cessation, 
and breast cancer awareness. Although many of the health 
promotion/education materials are obtained from outside 
sources, the materials/programs for smoking cessation and 
blood lead screening are developed by EHPM. 

Medical Information Management System (MIMS). 

MLMS serves MED as an administrative support and provides 
the basis for epidemiological investigations regarding health 
risks among the foreign affairs community. 

The Office of Safety', Health, and Environmental Man- 
agement (SHEM). SHEM conducts occupational health and 



U^ 



Prevention '93/'94: Federal Programs and Progress 



© 



safety assessments throughout the world. Assessment of the 
worksite to comply with Department of State policy or OSHA 
regulations falls under this office's mandate. SHEM manages 
and conducts training in a number of safety and occupational 
health areas, such as defensive driving, electrical safety, proper 
warehousing and maintenance operations, respiratory protec- 
tion, and confined space operations, to ensure that occupa- 
tional and job injuries, illnesses, and hazards are reduced. 

The Office of Foreign Building Operations (FBO). FBO 

provides oversight and technical assistance to ensure that con- 
tractors performing overseas construction activities comply 
with contractual requirements for occupational safety and 
health. Other offices within FBO are responsible for asbestos 
inspection and control, elevator and fire safety, and radon mit- 
igation. FBO has ongoing programs that address all aspects of 
building design, construction, renovation, and maintenance in 
order to provide a safe working environment for Department 
personnel. 

During fiscal years 1993 and 1994, additional preventive 
health attention will be placed on the development of a model 
fitness program, primarily for implementation by MED's 
overseas medical officers. The program will outline screening 
methodologies, fitness assessments, and fitness goal setting, 
accomplished with a minimum of equipment and without ded- 
icated exercise facilities. The Department continues to reduce 
environmental lead exposure with the development and im- 
plementation of a lead-based paint policy, which will comple- 
ment the ongoing blood lead screening program. FBO will 
develop a potable water control program and an underground 
storage tank assessment program. 



Department of 
Transportation (dot) 



The Department of Transportation plays an important role 
in transportation safety and in mitigating the environmental 
impacts of transportation. Prevention-related activities are 
conducted by the Office of the Secretary of Transportation 
and by various DOT agencies: the Coast Guard for marine 
environmental protection, for the protection of the health and 
safety of fishermen and maritime workers, and for boating 
safety; the Federal Aviation Administration, for safety and se- 
curity of civilian aircraft, personnel, and freight as well as 
noise and pollution control; the Federal Railroad Administra- 
tion, for railroad standards, safety, and consumer information; 
the Research and Special Programs Administration, for safet) 
in the transportation of hazardous materials and for pipeline 
safety, as well as for the variety of safety research and develop- 
ment programs supported by the Volpe National Transporta- 
tion Systems Center and the Transportation Safety Institute; 
and the Federal Transit Administration (formerly the Urban 
Mass Transportation Administration), for encouraging the 
sale use of buses and rail transit by the elderly and people with 
disabilities. Roughly 95 percent of all transportation injuries 
and fatalities arc highway-related. The National Highway 
Traffic Safety Administration sets safety standards for new 
motor vehicles, conducts public information programs, and 



implements other programs to reduce deaths, injuries, and 
economic losses from traffic accidents. The Federal Highway 
Administration deals with the safety of highways and of motor 
carriers that share the highways. 



National Highway Traffic Safety 
Administration (nhtsa) 

Traffic crashes are the leading cause of death for even,' age 
group from 6 to 33 years old. Motor vehicle-related crashes 
are responsible for approximately 40,000 fatalities and hun- 
dreds of thousands of injuries each year. Alcohol is associated 
with nearly half of these crashes. The estimated annual cost 
to the public is $137.5 billion in property damage, lost pro- 
ductivity, and medical and other expenditures. Within 
NHTSA, the Traffic Safety Program emphasizes occupant 
protection, alcohol and drug countermeasures, emergency 
medical services, police traffic sendees, motorcycle safety, bi- 
cycle, and pedestrian safety programs. The modification of 
vehicles to make the operation of motor vehicles more forgiv- 
ing of operator error (crash avoidance) and the vehicle less 
likely to cause injury or death if a crash does occur (crashwor- 
thiness) are the subjects of research and development and 
NHTSA rulemaking-. 



NHTSA Prevention Highlights 

Occupant Protection. The regular use of occupant protection 
devices, including manual and automatic safety belts and air 
bags, can reduce by almost half the likelihood of a passenger 
fatal injury in a serious automobile crash. Safety belt use in the 
United States is on the rise, with belt use increasing from 1 1 
percent in 1982 to 62 percent as of December 1992. This dra- 
matic improvement in safety belt usage results primarily from a 
combination of public information, legislation, and enforce- 
ment of State safety belt use laws. As of May 1993, 42 States, 
Puerto Rico, and the District of Columbia have enacted safety 
belt use laws. In States with such laws, usage rates are an average 
of 27 percent higher than the average in States with no laws. 
Some communities report usage rates as high as c '0 percent. \n 
estimated 5,500 lives were saved in 1992 alone because of safety- 
belt use. As a result of its recent success in raising national usage- 
above 60 percent, NHTSA is continuing to promote holiday 
campaigns that combine intensified enforcement with public in- 
formation. A similar approach has resulted in usage rates above 
85 percent in Canada. NHTSA will continue its outreach ef- 
forts to public and private sector agencies to generate increased 
program activity and to expand communication channels. In- 
creasing emphasis will be placed on developing program strate- 
gies and materials for hard-to-reach audiences. 

Child Passenger Safety. NHTSA coordinates a national 
program of technical assistance, training, and public informa- 
tion and education to reduce the number of injuries and fatali- 
ties to children resulting from non-use of seat belts or child 
safety seats in motor vehicle crashes. Assistance is provided to 
State and local government agencies, national organizations 
and their affiliates, employers, civic and volunteer organiza- 
tions, and other communitv advocates to coordinate and in- 
crease the impact of child passenger safet} programs. \\ hile 



Agency Innovations 



usage rates have increased in some populations, lack of use and 
incorrect usage are still significant problems that NHTSA is 
addressing. The agency also targets programs to increase the 
use of safety belts by all members of the family and increase 
the use and availability of child safety seats. All 50 States, the 
District of Columbia, and Puerto Rico have child passenger 
protection laws; however, there are gaps in coverage. NHTSA 
works with States and national law enforcement associations 
to develop public information campaigns, other programs, and 
support materials for increased enforcement of State child 
passenger safety laws. NHTSA also provides information to 
the public concerning recalls of child safety seats and investi- 
gates consumer complaints regarding possible defects. 

Impaired Driving. Alcohol involvement in fatal crashes has 
dropped substantially in the past decade. The proportion of 
fatal crashes involving alcohol fell from 57 percent in 1982 to 
46 percent in 1992. The reduction was greatest among the 15- 
to 20-year-old age group, a group historically at high risk for 
traffic crashes. NHTSA estimates that minimum drinking age 
laws (now at age 21 in all 50 States and the District of Colum- 
bia) saved over 13,000 lives between 1982 and 1991. Greater 
public awareness of impaired driving, tougher impaired dri- 
ving laws, and better enforcement of these laws have also con- 
tributed to this decline. NHTSA has joined with the National 
Transportation Safety Board and other government, industry, 
and safety groups to encourage States to pass laws that admin- 
istratively suspend the driver's license of individuals who fail 
an alcohol breath test and to lower the legal blood alcohol 
concentration (BAC) limit from .10 g/dl to .08 g/dl for adult 
drivers. NHTSA encourages States to enforce these laws 
using sobriety checkpoints and other enforcement methods. 
NHTSA is currently conducting a new enforcement demon- 
stration to determine the optimal method for the operation of 
sobriety checkpoint programs. NHTSA assists States by re- 
viewing their impaired driving programs through a week-long 
assessment by a group of experts drawn from other States, 
universities, and private organizations. Incentive grant fund- 
ing is available to States with administrative license revocation 
and .08 BAC laws, checkpoints, and other components of an 
effective impaired driving program. 

NHTSA continues to focus on young drivers as a high-pri- 
ority element of die impaired driving problem and will encour- 
age all States to adopt "zero tolerance" laws that make it illegal 
for anyone under the age of 2 1 to operate a motor vehicle after 
consuming any alcohol. NHTSA also continues to promote 
provisional licensing systems that gradually remove restrictions 
from young persons' driving privileges as they demonstrate 
their ability to drive responsibly. NHTSA is developing work- 
site programs to educate young workers in all aspects of traffic 
safety and to work with communities to establish comprehen- 
sive youth traffic safety prevention and education programs. An 
example is a project with the Washington, DC, Regional Alco- 
hol Program to develop and implement a model community- 
based program to reduce underage drinking and driving. 

A coalition of community, government, and private sector 
groups promoted the first National Drunk and Drugged Dri- 
ving (3D) Prevention Month in December 1992. The coali- 
tion prepared and distributed 60,000 program planner kits 
with resource guides, activity suggestions, planning guides, 
sample editorials and proclamations, and camera-ready art to 
assist communities in planning and conducting their own pre- 



vention activities. The coalition also conducted a major press 
conference to gain national media attention. 

NHTSA will continue other collaborative impaired driving 
efforts, including Techniques for Effective Alcohol Manage- 
ment (TEAM), a coalition of sports leagues, media, conces- 
sionaires, facility managers, and other organizations to reduce 
drinking at public facilities and sports stadiums. The agency 
will work with the Network of Employers for Traffic Safety 
(NETS), a coalition of employers, to develop and implement 
worksite traffic safety programs. NHTSA also will continue its 
close collaboration with public health and medical profession- 
als to ensure effective planning and implementation of traffic 
safety programs and will encourage State and local jurisdictions 
to establish self-sufficient mechanisms for funding programs. 

Pedestrian Safety. In 1991, approximately 14 percent of all 
traffic fatalities were pedestrian deaths. Another 86,000 pedes- 
trians were injured. Children between the ages of 5 and 15 
constitute 11 percent of all fatally injured pedestrians; adults 
over the age of 70 comprise another 18 percent. While chil- 
dren between the ages of 5 and 1 5 are commonly targeted by 
traffic safety and public health organizations in prevention ef- 
forts, programs directed at older pedestrians are just beginning 
to be developed. Alcohol is a major factor in pedestrian crashes, 
as nearly 40 percent of pedestrian fatalities involved alcohol. 

The three essential components of pedestrian safety pro- 
grams are public information and education, law enforcement, 
and traffic engineering design and improvements. NHTSA 
and the Federal Highway Administration have joined forces 
with the National Safety Council to develop a comprehensive 
pedestrian package for State and local traffic safety agencies 
called Walk Alert. 

Bicycle Safety. In 1991, 841 bicyclists were killed and an- 
other 66,000 were injured in traffic crashes. Approximately 17 
percent of these bicyclist fatalities involved alcohol. Although 
children under 15 years of age represented 37 percent of all 
bicyclists killed or injured, the number of adult bicyclists in- 
volved in traffic crashes has increased. 

Comprehensive bicycle safety programs include public in- 
formation, bicycle rider training, and bicycle helmet cam- 
paigns. The use of bicycle helmets is the most effective strat- 
egy to reduce bicyclist injuries and fatalities. Studies have 
shown that using bicycle helmets can reduce head injuries by 
up to 85 percent. State and local bicycle helmet laws have been 
enacted, typically requiring children under a certain age to 
wear a helmet while riding a bicycle. 

Motorcycle Safety. In 1991, 2,808 motorcyclists died in traf- 
fic crashes. Head injury is the leading cause of death in motor- 
cycle crashes, but motorcycle helmets reduce the risk of head 
injur}' substantially. Compared to a crash-involved helmeted 
motorcyclist, an unhelmeted rider is 40 percent more likely to 
incur a fatal head injury and 1 5 percent more likely to incur a 
serious head injury. 

NHTSA supports public information and education, legis- 
lation, regulation, and enforcement programs to increase mo- 
torcycle helmet usage and works with national, State, and local 
organizations to promote motorcycle safety and helmet use. In 
1993, 25 States, the District of Columbia, and Puerto Rico re- 
quire all operators and passengers to wear helmets; 22 States 
require helmet use for some riders (usually riders under 18 



© 



Prevention '93/'94: Federal Programs and Progress 



© 



years of age); and 3 States have no helmet use requirements. 
Over 90 percent of motorcyclists use helmets in States with 
laws covering all riders. Just 34 to 54 percent of motorcyclists 
in the remaining States use helmets. From 1984 through 1991, 
motorcycle helmets saved the lives of more than 5,200 motor- 
cyclists. An additional 5,600 lives would have been saved if all 
motorcyclists had worn helmets. 

Motorcycle operators involved in fatal crashes frequently 
are impaired by alcohol — more frequently than passenger car 
drivers. In addition, over 40 percent of motorcycle operators 
involved in fatal crashes are not properly licensed to operate 
motorcycles. In 1992, NHTSA released a law enforcement 
training program designed to assist in detecting impaired rid- 
ers. In 1993, NHTSA began a national campaign to increase 
the number of properly licensed motorcyclists. 

Trauma Prevention. The public is a vital part of the Emer- 
gency Medical Services (EMS) system, activating the EMS 
system and providing effective bystander care. EMS providers 
must therefore educate and inform the public and improve the 
public's understanding of EMS. NHTSA is developing a Pub- 
lic Information, Education, and Relations manual for EMS 
providers through a grant with the Metropolitan Dade 
County (Florida) Office of Trauma Services. The U.S. Fire 
Administration is also participating in this project. 

National Standard Curriculum for Bystander Care pro- 
gram, which also was developed under a grant with the Metro- 
politan Dade County (Florida) Office of Trauma Services, de- 
scribes a few actions a bystander must take that are most 
critical for a victim's survival from motor vehicle crashes. The 
intended audience includes rural communities (including Na- 
tive American populations), truck drivers, and young children. 
NHTSA anticipates that several different and innovative de- 
livery methods for bystander care training will be demon- 
strated and plans to conduct a demonstration project to pilot 
test and evaluate the Bystander Care Program. 

Older Driver Safety. In response to recent increases in fatali- 
ties and crash rates among older occupants of vehicles, 
NHTSA is developing procedures and screening tools to 
identify those drivers with declining functional capabilities 
who are no longer able to safely operate a vehicle. A coordi- 
nated research program with other government agencies that 
have expertise with older adults in the areas of crashworthi- 
ness, crash avoidance, and driver safety is being conducted. 
NHTSA is also developing materials to assist individuals, fam- 
ilies, medical personnel, and State driver licensing depart- 
ments to help drivers with declining functional capabilities de- 
cide when they should, or should not, drive. 

Motor Vehicle Safety. The safety performance of today's 
motor vehicles has been enhanced by new technology. Dri- 
ver anil passenger-side air bags arc standard in many new 
cars in response to Federal requirements. .Anti-lock brakes 
are being offered in response to market demand. Both 
XI ITS A ami the automotive industry continually search for 
new designs and technologies to address problems in auto- 
motive safety and to make the operation ot motor vehicles 
more forgiving ot operator error. The crash safety ot new 
passenger cars and light trucks of the 1990s will be improved 
by federal requirements promulgated tor frontal and side 
impact protection. XI ITSA is also preparing rulemakings in 



vehicle rollover, head injury- protection, and heavy truck 
anti-lock brakes. 



Federal Highway 
Administration (fhwa) 

Office of Highway Safety 

As the Nation's highways have become more complex and 
sophisticated, the role of the FHWA's Office of Highway 
Safety has expanded from one of encouraging States to imple- 
ment safety improvements on the Federal-aid highway systems 
to one of providing leadership and funding for a wide range of 
safety programs. In addition to the emphasis placed on safety 
during construction and reconstruction of the Interstate and 
other Federal-aid highways, other programs emphasize road- 
way, roadside, and operational improvements to reduce the 
number and severity of traffic crashes. Included among these 
improvements are wider lanes and shoulders, extension of cul- 
verts, removal of roadside hazards, and the use of standard pave- 
ment markings, signs, and traffic signals. 

Office of Highway Safety Prevention Highlights 

Highway Safety Improvement Program. Since the start of the 
Rail-Highway Crossings Program in FA" 1974, nearly S2.5 bil- 
lion has been obligated by the States for more than 26,700 pro- 
jects to install signs, markings, flashing light signals, automatic 
gates, and crossing surface improvements. Evaluations of im- 
provements made under this program show that between 1974 
and 1991, 6,800 fatalities and 28,500 nonfatal injuries were pre- 
vented. Under the Hazard Elimination Program, almost S4 bil- 
lion has been obligated since 1974 for 31,000 projects, which 
have prevented over 20,500 fatalities and 565,000 nonfatal in- 
juries. Approximately $400 million per year has been authorized 
by the Intermodal Surface Transportation Efficiency Act of 
1991 to carry out these programs in FY 1992-1997. 

Section 402 Highway-Related Safety Grants. Adminis- 
tered in the States by the Governors' Highway Safety Repre- 
sentatives, the Section 402 highway safety program supports 
safety construction and traffic improvements. Activities in- 
clude improved safety data collection and programming sys- 
tems, special problem studies ami analyses, training and tech- 
nical guides, and purchasing equipment to improve safely 
problem identification and countermeasure selection. 

Work Zone Safety. Work zone safety continues to grow in 
importance as more and more streets and highways are main- 
tained and constructed in areas with traffic. Fatalities in work 
zones increased from about 500 in 1982 to more than 680 in 
1991, with over 30 percent occurring on freeways. Special 
programs are underway to provide training for contractors 
.mil State and local highway personnel on planning and .sched- 
uling work zone traffic operations anil the design and opera- 
tion ol work zone traffic control. 

Operation Lifesaver. Operation Lifesaver, with its emphasis 
on educating the public about hazards at highway-railroad 



Agency Innovations 



crossings, complements the engineering improvements that 
have been made under the FHVVA Rail-Highway Crossings 
Program. This national public information and education pro- 
gram on the hazards at highway-rail crossings was funded at 
$300,000 annually for 6 years (FY 1992-1997). 

Hazardous Materials Routing. The Hazardous Materials 
Transportation Uniform Safety Act of 1990 requires States to 
comply with Federal safety standards of routing hazardous 
materials. On August 31, 1992, the FHWA published in the 
Federal Register a Notice of Proposed Rulemaking and a No- 
tice of Public Hearing for routing of placarded non-radioac- 
tive hazardous materials in preparation for issuing the Final 
Rule in mid- 1993. 



Research and Special Programs 
Administration (rspa) 

RSPA's overall program is geared toward increasing the 
public's awareness of the risks involved in transporting haz- 
ardous materials, and promoting compliance with the regula- 
tions. RSPA's two major goals are the prevention of hazardous 
materials accidents and the reduction of the consequences that 
occur from them. RSPA provides documents on an electronic 
bulletin board called the Hazardous Materials Information 
Exchange or HMIX. For information on access, call 1-800- 
PLAN-FOR. A publication list and public information are 
available by calling (202) 366-2301. 



RSPA Prevention Highlights 

Emergency Response Guidebook (ERG). The ERG addresses 
all hazardous materials regulated by DOT and provides sug- 
gested initial response actions in the event of a spill, explosion, 
or fire. The goal is to have tine ERG in even" emergencv re- 
sponse vehicle nationwide. More than 5.2 million copies of the 
ERG have been distributed. It is updated triennially to accom- 
modate new products and changes in technology. 

In 1992, DOT increased its role in emergency response 
planning and training. Losing registration fees collected from 
certain transporters and shippers of hazardous materials, RSPA 
is implementing a reimbursable grant program for State and 
local emergency response planning and training programs. 



Federal Railroad 
Administration (fra) 

In 1991, over 2,600 reportable train accidents resulted in 19 
fatalities and 326 non-fatal injuries. Hazardous materials were 
released in 47 accidents. Over 95 percent of all rail-related fa- 
talities in 1991 resulted from accidents at highway-rail cross- 
ings or trespassing. In 1991, there were over 5,300 crossing 
accidents, with 608 fatalities and over 2,000 injuries. Tres- 
passer fatalities numbered 542. 

FR.A Prevention Highlights 

National Inspection Plan (NIP). This plan uses accident/in- 
cident and inspection data, passenger and hazardous material 
traffic data, and other risk factors to provide direction to 349 



Federal and 126 State inspectors who enforce regulations cov- 
ering track, rolling stock, signals, operations, and the trans- 
portation of hazardous materials. 

Highway-Rail Grade Crossings. In 1991, nearly 95 percent 
of all railroad-related fatalities resulted from crossing acci- 
dents or trespassing. To address this problem, the FRA has 
developed crossing safety initiatives emphasizing elimination 
of highway-rail crossings (25 percent bv the year 2000); engi- 
neering improvements (including research on improved and 
innovative warning devices); enforcement of traffic laws at 
crossings and no trespassing laws; development of safety regu- 
lations and standards; and public education about crossing 
safety and trespasser prevention. 



United States Coast Guard 
(Coast Guard) 

The Coast Guard's many missions extend from the North to 
South pole and include such varied activities as iceberg patrol in 
the North Atlantic, drug smuggling interdiction in the 
Caribbean, fishing monitoring in the Gulf of Alaska, safety pa- 
trols on the Mssissippi River, responding to oil spills on any 
waterway, conducting search and rescue on any coast and in the 
Great Lakes, and teaching boating safety. The Coast Guard li- 
censes mariners, inspects ships, administers port security, main- 
tains buoys and other navigation aids, and performs a myriad of 
other tasks to protect lite, property and the environment. 

Coast Guard Prevention Highlights 

Occupational Health Programs for Merchant Mariners. 

The Coast Guard published a voluntary standard for the pro- 
tection of merchant mariners from occupational health prob- 
lems. Promulgated as a Navigation and Vessel Inspection Cir- 
cular in February 1992, the standard provides the marine 
industry with guidance for a comprehensive health and safety 
program. It outlines a method for evaluating hazards and es- 
tablishing effective procedures for minimizing exposure of 
employees. There are provisions for exposure monitoring, 
training, and development of safe work procedures. Common 
hazards such as confined space entry, engine room asbestos, 
carbon monoxide, and noise are also addressed. 

Benzene Exposures. The Coast Guard implemented regula- 
tions to reduce worker exposure to benzene, a large volume 
chemical that causes cancer (primarily leukemia) and other dis- 
eases. These rules require vessel owners to measure the benzene 
vapor concentration aboard ships and barges whenever there is 
more than 0.5 percent benzene in the liquid phase (benzene is 
common in gasoline and crude oil). If above the permissible ex- 
posure level, the vessel owner must develop and implement a 
plan to reduce exposures. The regulations also require initial, 
annual, and emergency medical tests. Providing comprehensive 
protection to workers will save 323 lives over the next 45 years. 

Recreational Boating Safety. Following a generally down- 
ward trend in the number of boating fatalities from an average 
1,500 per year in the early 1970s to 1,200 in die early 1980s, 
boating fatalities decreased each year from 1,116 (6.7 fatalities 
per 100,000 boats) in 1985 to 865 (4.4 per 100,000 boats) 



^fe 



Prevention '93/'94: Federal Programs and Progress 



1990. This trend was reversed in 1991, when 924 boaters lost 
their lives (4.6 per 100,000 boats). It is estimated that at least 
half of the fatal boating accidents involve excessive alcohol con- 
sumption. A recent Coast Guard study showed that intoxicated 
boaters are nearly 1 1 times more likely to die in a boating acci- 
dent than sober boaters. Federal law prohibits the operation of a 
recreational boat by those with a blood alcohol concentration of 
0.10 percent or above. The Coast Guard continues to strongly 
encourage States to pass laws that meet or exceed this criterion, 
and provides alcohol enforcement training to State officers. 
The Federal/State partnership is enhanced by boating safety* fi- 
nancial assistance administered bv the Coast Guard. 

Boater education course materials are being reviewed and 
revised to ensure compliance with basic Federal guidelines. 
Grants to public service organizations have enhanced existing 
boating safety public information efforts, including National 
Safe Boating Week. The Coast Guard Auxiliary, a 35,000- 
member volunteer organization, continues to teach boating 
safety courses, provide safety patrol support, and give safety 
examinations for recreational boats. The provision of addi- 
tional personnel to inspect 2,500 domestic boat manufacturing 
facilities will ensure that more boats are being built to Federal 
safety standards. The Coast Guard also tests boats for compli- 
ance with the standards. 

Alternative methods of collecting boat accident information 
are being investigated to provide more accurate and complete- 
accident data for prevention research and analysis purposes. 
The toll-free "800" Boating Safety Hotline has been enhanced 
so that information received on potentiallv unsafe boats or 
equipment can be collected, compiled, quantified, and for- 
warded for immediate remedial action. The Coast Guard 
monitors manufacturer boat recall campaigns. 



Office of the Secretary of 
Transportation (ost) 

The Secretary of Transportation provides leadership and 
coordination for all programs in DOT to prevent injury and 
loss of lite resulting from transportation activities. 

OST Prevention Highlights 

Alcohol and Drugs in the Transportation Workplace. 

DOT has long had a concern for the deleterious effect of 
drugs and alcohol on both the safety of the traveling public 
and on the lives of transportation workers. In 1993, proposed 
regulations that would require extensive alcohol testing, in- 
cluding random testing, ol more than 7 million workers in 
safety sensitive positions in aviation, rail, highway, transit, and 
pipeline transportation were developed. The rules require 
evaluation and possible treatment for any worker found with a 
breath alcohol concentration of 0.04 percent and, as a safety 
precaution, would temporarily remove from duty those with a 
lower breath alcohol concentration down to 0.02 percent. The 
rules would also strengthen the ongoing drug testing program 
and provide for better data collection to e\ aluate the effective- 
ness ol the program. 

Smoke-Free Transportation. OST carried out a study in 
which the air quality was measured onboard ( >2 randomly se- 
lected commercial fligbts where smoking was limited to certain 



sections of the cabin. Because all pressurized airliners recircu- 
late cabin air, the study showed potentially harmful levels of 
smoke contaminants in the air of non-smoking sections. The 
findings of this study were instrumental in the enactment of a 
statute to ban smoking on almost all domestic flights. An OST 
proposal to seek a ban on smoking on international flights re- 
sulted in the United States being a sponsor of a resolution 
adopted by the International Civil Aviation Organization call- 
ing for the phase out of smoking on all international flights by 
July 1, 1996. 

Earthquake Protection. To protect the safety of occupants of 
transportation-related structures, OST has proposed setting 
standards for seismic reinforcement of all new buildings built 
by or for DOT. The standards would be keyed to expected 
earthquake likelihood and severity in different areas of the 
country, and would reduce the chance of building collapse with 
subsequent injuries and loss of life should an earthquake occur. 

Commercial Space Transportation. The Office of Com- 
mercial Space Transportation has the responsibility for the li- 
censing of private commercial firms for the use of expendable 
rockets in the launching of space vehicles. A critical part of the 
licensing procedure is the determination that the applicant has 
a satisfactory' safety plan to ensure that the proposed launches 
will not endanger persons in the launch area or the recovery- 
area, if the vehicle is to be recovered. 



Department of the 
Treasury (treasury) 



Certain regulatory and law enforcement agencies of the De- 
partment of the Treasury provide health-related prevention 
activities to the public. As an example, the Bureau of Alcohol, 
Tobacco, and Firearms (ATF) regulates the alcohol, tobacco, 
legal firearms, and explosive industries. DHHS works with 
ATF on the labeling of ingredients and substances that may 
pose a public health problem. 



Treasury Prevention Highlights 

Consumer Actions. ATF continues to test alcoholic bever- 
ages to determine levels of Ethyl Carbamate (EC) in various 
types of beverages. EC has been found to naturally occur dur- 
ing the production of certain alcoholic beverages. Chemical 
compounds in alcoholic beverages have been identified as pre- 
cursors to EC, which through production methods, react to 
become this carcinogen. Though FDA has taken the lead in 
negotiations with Congress, foreign governments, and the 
beverage industry regarding reducing EC levels in various 
products, \ IT is involved in industry negotiations. 

In January 1992, it was discovered thai certain wines from 
the VenetO region in Italy bail been adulterated with the pesti- 
cide Methyl [sothiocyanate (MITC). \ IT issued industry 
Circular 92-1, Procedures lor Importing Italian Wines, on 
March 16. 1992, which required importers to provide a certifi- 
cate of analysis lor wines from that region at the time of im- 



Agency Innovations 



portation, attesting to the absence of MITC. From the time 
Industry circular 92-1 was issued until August 1992, approxi- 
mately 1,300 certificates of analysis were received. It was de- 
termined that these certificates of analysis would be used to 
implement the random testing of pertinent wines. If follow-up 
analysis reflects the absence of MITC, ATF will rescind In- 
dustry Circular 92-1. 

ATF has initiated programs to determine the lead content 
in wines and also in some other beverage alcohol products. 
Primarily, the emphasis is on wines and especially wines with 
lead capsules. A market basket program has been in place to 
obtain samples of imported beverage alcohol products to 
monitor their lead content. In addition, a domestic lead adul- 
teration sampling program is in progress to assist wine pro- 
ducers in identifying the sources of lead contamination. This 
should result in reduced lead levels in wine. In ATF Industry 
Circular 91-11, issued October 3, 1991, the lead limit in table 
wines is 300 parts per billion. FDA, in consultation with ATF, 
is considering elimination of lead capsules to further reduce 
lead exposure to consumers. ATF published a notice of pro- 
posed rulemaking in the Federal Register on November 25, 
1992. This notice was part of FDA's continuing effort to re- 
duce lead levels in food. This notice is proposing to prohibit 
the use of tin-coated lead foil capsules on wine bottles. This 
action is based on evidence that the lead in these capsules may 
become a component of the wine. 



Department of 
Veterans Affairs (va) 



The Department of Veterans Affairs has had a Preventive 
Medicine Program since 1985. It is under the Veterans Health 
Administration (VHA), Office of Clinical Programs, Medical 
Service. Each VA medical center and independent outpatient 
clinic has a Preventive Medicine Program. The program is 
conducted within the medical care svstem and inter- 
ventions/services are provided to patients being cared for 
through that system. Each of the facilities has a medicine co- 
ordinator and there is a National Program Coordinator at VA 
Central Office. 



VA Prevention Highlights 

Preventive Medicine Program. The program focuses on risk 
factor interventions and services which represent diseases that 
have high mortality and morbidity in the VA patient popula- 
tion. These interventions include screening for hypertension, 
high cholesterol, and breast, cervical, and colorectal cancers; 
inquiry counseling for alcohol, nutrition/weight control, physi- 
cal fitness/exercise, and smoking; and influenza immunization. 
While activity is encouraged in all interventions, each year one 
intervention receives special emphasis. It is hoped that through 
highlighted interventions there will be a greater awareness of 
the importance of prevention and early detection. Special in- 
terventions were FY 1985-86, Influenza Immunization; FY 
1987, Colorectal Cancer Screening; FY 1988, Smoking Cessa- 
tion; FY 1989-90, Cholesterol Screening; FY 1991, Smoking 



Cessation; FY 1992, Alcohol Abuse: Diagnosis and Treatment; 
and FY 1993, Mammography. The program guidelines and 
goals were developed using the U.S. Preventive Services Task 
Force Guide to Clinical Prevention Services. A future area of em- 
phasis may be nutrition screening and counseling for the el- 
derly veterans. 

While there is notable activity in all preventive interven- 
tions, hypertension screening is the most frequently per- 
formed. There are increasing numbers of cholesterol screens 
and mammograms. There is a smoking control officer at each 
VA facility to administer the smoking policy and procedures 
and to coordinate the local smoking cessation program. Health 
care professionals consider prevention as essential to contin- 
uum of care particularly to meet the needs of aging veterans. 



Environmental 
Protection Agency (epa) 



The mission of the Environmental Protection Agency is to 
protect human health and the global environment from pollu- 
tion. Major EPA programs address air quality, water quality 
(including safe drinking water), pesticides, hazardous and solid 
waste, toxic substances, the protection ot groundwater and 
wetlands, and climate change. EPA coordinates and supports 
activities and research by State and local governments, public 
and private groups, individuals, and educational institutions. 
EPA also works with other Federal agencies to support their 
efforts to prevent or mitigate the impact of their own activities 
on human health and the environment. The research pro- 
grams at EPA are designed to identify potential environmental 
pollutants and to develop exposure monitoring techniques and 
pollution prevention and control techniques. EPA works to 
prevent, control, and respond to pollution using a broad range 
of tools, including research, information dissemination, stan- 
dard-setting, regulation, permits, enforcement, education, and 
collaborative activities with the public and the private sector. 



EPA Prevention Highlights 

EPA's Science Advisory Board has recommended that EPA 
should emphasize pollution prevention as the preferred option 
for reducing risk. In a 1993 Earth Day statement, pollution 
prevention was established as the guiding principle for envi- 
ronmental efforts. 

For EPA, pollution prevention does not simply mean reduc- 
ing exposure to pollutants. The most cost-effective and envi- 
ronmentally protective approach is to prevent the generation 
of wastes. It is not cost effective or environmentally effective to 
allow the generation of wastes and their disposal into the envi- 
ronment, attempt to establish safe levels of exposure, and then 
attempt to cleanup the environment to those levels. The Pollu- 
tion Prevention Act states a national policy 7 that pollution 
should be prevented or reduced at the source where feasible. 

EPA policy includes seven key components: 
• Incorporate multimedia prevention in all activities of 
EPA, including regulatory development, permitting, 
and enforcement; 



(f^ 



Prevention '93/'94: Federal Programs and Progress 



• Build a national network of prevention programs among 
State, local, and tribal governments; 

• Expand those environmental programs that emphasize 
cross-media prevention, reinforce the mutual goals of 
economic and environmental well-being, and represent 
new models for government/private sector interaction; 

• Establish new Federal partnerships to promote preven- 
tion; 

• Increase efforts to generate and share information to 
promote prevention and track progress through mea- 
surement systems such as the Toxic Release Inventory 
(TRI); 

• Develop partnerships in technological innovation with 
other agencies and the private sector to increase indus- 
trial competitiveness and enhance environmental stew- 
ardship; and 

• Seek changes, where justified, in Federal environmental 
laws that will encourage source reduction. 

TRI includes information on the type and quantities of 
toxic chemicals that companies are releasing into the environ- 
ment. Data are compiled from annual reports filed by the 
chemical companies. Since passage of the Emergency Plan- 
ning and Community Right-To-Know Act, TRI has become a 
cornerstone of efforts to identify, target, measure, and reduce 
toxic chemicals. TRI data are available to the public. 

In August 1993, President Clinton signed an executive 
order that requires Federal facilities to reduce emissions and 
report annually under TRI. EPA has proposed an expansion of 
the TRI list to include approximately 300 additional chemi- 
cals; a second phase of the expansion would increase the facili- 
ties that report under TRI. Beginning u nh the 1991 reporting 
year, companies also reported quantities of waste generated 
and the progress they had made in pollution prevention. 

Reducing Lead-Based Paint Hazards. Approximately one 
in every six children in the United States has a blood lead level 
that exceeds CDC-recognized safe levels. Childhood lead poi- 
soning is one of the most common and preventable pediatric 
health problems in the United States today. Young children, 
from birth to 6 years, are particularly susceptible to the toxic 
effects of lead. If pregnant women are exposed, fetuses may to 
subjected to lead. The process of eliminating lead-based paint 
hazards characteristically creates large amounts of lead dust. 
The ease with which lead contaminated dust is ingested by 
young children makes it especially important to control dur- 
ing the remediation process. To assure that the public is pro- 
tected, the workforce responsible for eliminating lead hazards 
must be properly trained to contain the dust. 

Although IT \ has had an active role in dealing with lead is- 
sues for many years, the regulatory component of F.PA's ef- 
forts to address lead hazards was expanded by Congress in the 
1 lousing and Community Development Act of 1992. Title X 
provides for a comprehensive national approach to dealing 
with lead hazards in the Nation's housing stock by mandating 
that regulatory and programmatic activities be undertaken by 
a number ol federal agencies. 



^g 



Federal Emergency 
Management Agency 
(fema) 



The Federal Emergency Management Agency (FEMA) is 
the focal point within the Federal Government for emergency 
planning, preparedness, mitigation, response, and recovery. 
FEMA works closely with State and local governments bv 
funding emergency programs and providing technical guid- 
ance and training. These coordinated activities at the Federal, 
State, and local levels ensure a broad-based emergency pro- 
gram to protect public safety and property. FEMA was estab- 
lished in the executive branch as an independent agency pur- 
suant to Reorganization Plan No. 3 of 1978 (5 U.S.C. Appl.l) 
and Executive Orders 12127 of March 31, 1979, "Federal 
Emergency Management Agency," and 12148 of July 20, 
1979 "Federal Emergency Management." 



FEMA Prevention Highlights 

National Preparedness Capability. The National Prepared- 
ness Directorate develops and coordinates the national policy, 
programs, and facilities necessary for attaining and maintain- 
ing the Federal Government's capability to deliver effective 
emergency management during all phases of national security 
and/or catastrophic emergencies. 

State and Local Programs. The State and Local Programs 
and Support Directorate administers programs in support of 
State and local governments that are designed to improve 
emergency planning, preparedness, mitigation, response, and 
recover}' capabilities at the State and local levels in an all haz- 
ards context. They are responsible for coordinating the devel- 
opment of the Federal Response Plan, the plan for a Federal 
response to a catastrophic disaster; administering the Presi- 
dent's Disaster Assistance Program, which provides supple- 
mental Federal assistance in declared disasters and emergen- 
cies; leading and administering the National Earthquake 
Hazards Reduction Program, which is a comprehensive miti- 
gation program designed to reduce loss of lives and property 
from future earthquakes; and administering the Emergencj 
Food and Shelter Program, which provides grants to private 
nonprofit organizations tor temporary food and shelter ser- 
vices lor homeless persons. 

Federal Insurance. The federal Insurance Administration 
administers the National Flood Insurance Program (NFIP) 
and the federal Crime Insurance Program (FCIP). fhe NFIP 
is a federal program that makes flood insurance available to 
residents of communities that adopt and enforce the NFIP's 
floodplain management regulations to reduce future flood 
Inssis. There are 18.2 10 communities participating in NFIP, a 
self-supporting program requiring no taxpayer funds to pay 
claims or operating expenses, fhe FCIP authorizes the fed- 
eral Government to sell crime insurance at affordable rates in 
any eligible Stale, fhe FCIP offers protection to home and 



Agency Innovations 



business owners against financial loss from burglary and rob- 
bery. There are currently 1 1 States participating in the FCIP. 

Fire Policy. The United States Fire Administration (USFA) 
provides leadership, coordination, and support for fire preven- 
tion and control, hazardous materials, and emergency medical 
services activities. USFA develops and disseminates fire safety 
information to fire services and the general public. Through 
its National Fire Academy, USFA develops and delivers train- 
ing and education programs to fire service personnel. USFA is 
also responsible for the activities of the National Fire Data 
Center and the management of the National Emergency 
Training Center in Emmitsburg, Maryland. USFA works 
closely with national fire service organizations; Federal, State, 
and local government agencies; and the private sector to de- 
velop and implement programs to significantly reduce the Na- 
tion's fire deaths, injuries, and property losses. 



Federal Trade 
Commission (ftc) 



The Federal Trade Commission is responsible for enforc- 
ing the antitrust laws and for protecting consumers from un- 
fair or deceptive acts or practices in the marketplace. With 
respect to disease prevention and health promotion, FTC en- 
gages in four principal activities. First, it develops law en- 
forcement initiatives designed to prevent the dissemination of 
false or deceptive information about health-related products 
and services. Second, it enforces antitrust laws to increase ac- 
cess by patients to affordable health care and to remove un- 
reasonable restraints on the marketing arrangements of 
health care providers. Third, it conducts economic studies, 
which often serve as a basis for casework in the Bureau of 
Consumer Protection or Competition. Fourth, it conducts 
education efforts to assist consumers in selecting and using 
the services of providers of health care and in avoiding the 
harms caused by fraud schemes and other deceptive health- 
related practices. 



FTC Prevention Highlights 

Orders Prohibiting Unfair or Deceptive Advertising. The 

FTC has issued orders or obtained injunctions prohibiting un- 
fair or deceptive advertising or marketing of diet products and 
diet programs; health care services such as cosmetic surgery; 
procedures to treat infertility; and foods and food supple- 
ments. The FTC also obtained several settlements with food 
companies for allegedly deceptive advertising about the fat 
and cholesterol content of their products. These companies 
are prohibited from making unsubstantiated health claims in 
the future. 

Orders Prohibiting Restraints on Advertising by Health 
Care Professionals. To facilitate consumer access to infor- 
mation they may need in choosing health care services and 
providers, the FTC seeks to eliminate unreasonable restraints 
on truthful, nondeceptive advertising by health care profes- 



sionals. In a recent proceeding, for example, the FTC charged 
that a State chiropractic association had conspired to restrict 
competition through advertising restrictions, including prohi- 
bitions on the truthful advertising of price discounts, free ser- 
vices, and claims of unusual expertise. 

Orders Prohibiting Unfair Methods of Competition. To 

promote the availability of affordable health care services, the 
FTC has issued a number of orders settling charges of unfair 
methods of competition. Orders prohibiting price fixing, boy- 
cotts, and staff coercion were issued. 

Eyeglass Prescription Release Rule. The FTC voted to 
continue its trade regulation rule requirement that op- 
tometrists and ophthalmologists provide consumers with a 
copy of their eyeglass prescription, at no extra cost, immedi- 
ately after an eye exam. 

Economic Studies. FTC staff economic studies examine the 
effects of market forces and regulations on the prices of health 
care services and products. A 1990 study examining the costs 
and benefits of occupational regulation noted the relatively 
large costs to consumers of licensure in certain health care 
professions. The report suggests several alternative forms of 
regulation that may impose less cost for consumers while 
maintaining appropriate quality levels. 

Consumer Education. To promote health education in 
areas where it has pursued investigations and cases, the FTC 
has produced more than a dozen health-related, multimedia 
consumer education campaigns over the past 10 years. 

The Facts About Weight Loss Products and Programs, presented 
in 1992 as a multi-media public service campaign by the 
FTC, the Food and Drug Administration, and the National 
Association of Attorneys General, was designed to help 
consumers avoid scams and encourage them to consider the 
costs and the consequences of their dieting decisions. 

Diet Programs, a brochure published in 1990, warns con- 
sumers that there is evidence that only a small proportion 
of people maintain weight loss for any significant time 
after using programs that promise easy, quick, or perma- 
nent weight loss and use liquid diets or require special 
diet regimens. 

Hearing Aids, developed in cooperation with the American 
Association of Retired Persons (AARP) in 1991, provides 
information about hearing loss and what to look for when 
shopping for a hearing aid. It stresses the importance of a 
medical exam and the value of a hearing aid trial period. 

Cosmetic Surgeiy, published in 1991, stresses the impor- 
tance of selecting a doctor who is well-trained and experi- 
enced in performing specific procedures. It provides 
questions consumers may want to ask doctors they are 
consulting. It also lists some common cosmetic surgery 
procedures and their potential risks. 

Infertility Seiuices, a brochure published in 1990, provides 
information to help consumers better evaluate success-rate 
claims and select the best program for their specific needs. 



€} 



Prevention '93/'94: Federal Programs and Progress 



Food Advertising Claims, a brochure published in 1992, de- 
scribes fat, no or low cholesterol, and "light" claims in ad- 
vertisements. It also alerts consumers to the Food and 
Drug Administration's new food labeling regulations. 

Healthy Questions, a booklet developed in cooperation 
with AARP, explains how to select and use the health care 
services of physicians, pharmacists, dentists, and vision 
care specialists. 

Health Claims: Separating Fact From Fiction, a brochure 
published in 1986, aims to help consumers recognize and 
avoid health fraud schemes. This publication is available 
in English and Spanish. 

Eye Care, a brochure published in 1987, explains the 
FTC's Eyeglasses Rule and the various types of eye care 
professionals. It also gives some suggestions about shop- 
ping for eye care, especially contact lenses. 

Generic Dnigs, a television public service announcement 
and brochure campaign, defines the term "generic drug" 
as well as other drug terminology. The Drug Product Se- 
lection Law is also explained. 

Sunscreens, a videotape and brochure education campaign 
produced in 1990, provides information about sun expo- 
sure and sunscreen protection. 

Indoor Tanning, a brochure published in 1988, explains 
how indoor tanning devices work and describes the risks 
associated with using them. 



U.S. Consumer 
Product Safety 
Commission (CPSC) 



The U.S. Consumer Product Safety Commission is an in- 
dependent regulatory agency created in 1973 to protect con- 
sumers from unreasonable risks of injury associated with con- 
sumer products. CPSC administers the Consumer Product 
Safety Act, the Flammable Fabrics Act, the Federal Hazardous 
Substances Act, the Poison Prevention Packaging Act, and the 
Refrigerator Safety Act. Because CPSC's mandate from Con- 
gress is to eliminate or reduce unreasonable risks of injury or 
illness that may be associated with consumer products, all of 
its activities involve the prevention of injury or diseases. 
CPSC continuously strives to identify those products that pre- 
sent the more serious safety problems for consumers and to 
deal with them on a priority basis. The National Electronic 
Iniurv Surveillance System (NE1SS) is a cooperative effort 
with randomly selected hospitals throughout the country that 
provides nationally representative (.lata about product-related 
injuries treated in emergency rooms. 



^^ 



CPSC Prevention Highlights 

Cigarette Lighters. Children playing with cigarette lighters 
caused an estimated 7,700 residential fires that resulted in 
about 160 deaths and 1,700 injuries annually during 
1988-1990. Children under age 5 ignited about three-quarters 
of these fires accounting for over 90 percent of the deaths and 
80 percent of the injuries. Children under age 5 were also fire 
victims, accounting for about three-quarters of the related 
deaths. CPSC initiatives to address this problem included de- 
velopment of a draft mandatory standard using a protocol for 
testing young children's ability to operate surrogate lighters 
(lighters redesigned to signal operability without a flame) and 
cooperation with lighter manufacturers to encourage develop- 
ment of a child-resistant cigarette lighter. 

Cigarette Fire Safety. More than one of every four fire 
deaths occurs in a fire started by a cigarette. During 1990, 
more than 1,200 persons were estimated to have died in such 
fires. The United States currently has one of the highest per 
capita fire death rates in the world. In an effort to address this 
problem, Congress enacted the Fire Safe Cigarette Act of 
1990 to assess the practicability of developing a performance 
standard to reduce cigarette ignition propensity. Specific 
tasks included developing a test method for measuring ciga- 
rette ignition propensity; collecting data about the character- 
istics of cigarettes, smokers, and materials ignited in ciga- 
rette-ignited fires; developing information about societal 
costs of cigarette fires; and investigating possible changes in 
smoke toxicity and resultant health effects of prototype igni- 
tion-resistant cigarettes. 

Swimming Pools. In 1989, 550 people are estimated to have 
drowned in residential swimming pools in the L T nited States. 
Some 300 of these were children under the age of 5. In addi- 
tion, in 1991, an estimated 2,300 children under the age of 5 
were treated in hospital emergency rooms for submersion in- 
juries. About 700 spinal cord injuries are estimated to occur an- 
nually in pools and other bodies of water. The objectives of 
CPSC's activities in this area are to reduce the number of child 
drownings and near-drownings in residential swimming pools 
and to reduce the number of diving deaths and injuries in all 
pools. The model guideline codes have adopted the CPSC rec- 
ommendations tor swimming pools, spas, and hot tubs. 

Playground Injuries. Through data from XEISS. CPSC' has 
long recognized the potential hazards that exist with tine use of 
playground equipment. Commission studies of more than 
200,000 playground-equipment-related injuries treated in 
L T .S. hospital emergency rooms each year indicate that the 
majority of injuries result from tails, primarily falls to the sur- 
face below the equipment. 

In 1991, CPSC staff published of a handbook of general 
satetv information lor public playgrounds tor use by school or 
park officials ami consumers in designing or maintaining new 
anil existing public playgrounds. Staff continues to participate 
in the development of and revisions to three technical volun- 
tary standards to be used by manufacturers and designers. 
These standards address hazards associated with public play- 
ground equipment, home playground equipment, and play- 
ground surfacing. 



Agency Innovations 



Riding Mowers. Statistics compiled from 1983 through 198° 
indicate that an estimated 19,600 injuries related to riding 
mowers were treated in U.S. hospital emergency rooms each 
year. The hospitalization rate for riding mower-related in- 
juries is almost twice die average rate for all injuries related to 
other products as reported through NEISS. The major haz- 
ards are blade contact and loss of stability. Analysis based on 
data from 1983 through 1986 showed that about half of the in- 
juries occurring during mower use were to persons under 16 
or over 55 years old. The majority of fatalities, estimated at 75 
deaths per year, involved mower overturning, mower run- 
ning/backing over a child or a bystander, and operator falling 
or being thrown from mower. About 60 percent of the deaths 
reported were children under 5 or adults over 65 years old. 
The goal of the riding mower project is to develop recom- 
mendations on dynamic stability, blade contact, and control 
layout by 1994. These recommendations may lead to im- 
provements to the voluntary standard that reduce deaths and 
injuries to the customers. 

Gas Detecrion/LP Gas Odorization. More than 400 deaths 
occur each year as a result of fire or carbon monoxide poison- 
ing from gas-fired heating equipment. Mortality data indicate 
that gas heating systems account for the majority of non-fire- 
related carbon monoxide deaths in the home. NEISS and 
other data reveal significant hazards associated with fires from 
water heaters, central furnaces, and space heaters, as well as 
carbon monoxide poisonings from room heaters and furnaces. 
Water heaters appear to be the largest single contributor to 
fire losses associated with gas heating equipment. Gas-fired 
heating appliances accounted for about 13,900 fires, 770 civil- 
ian injuries, and 190 fire-related deaths in 1990; of these to- 
tals, an estimated 5,800 fires, 430 civilian injuries, and 40 
deaths were associated with water heaters. Analysis of water 
heater fires reveals a larger portion of incidents involving LP 
gas than natural gas, relative to the number in use. 

CPSC has been successful in obtaining voluntary standard 
salety improvements for gas-fired central furnaces and vented 
room heaters to protect consumers from carbon monoxide 
poisoning. Also, pilot lighting instructions have been im- 
proved for gas-fired heating equipment with pilots, a change 
that is expected to reduce the injuries that occur when at- 
tempting to light the appliance. The opportunity to react to 
leaking LP gas by odor detection may be missed if odorant is 
lost due to oxidation in new tanks or absorption into masonry 
walls. The elderly are particularly vulnerable since 25 to 50 
percent of people over age 63 have reduced ability to detect 
odors. Staff will evaluate any new odorant recommended by 
industry, while also reviewing the state of the art for fuel gas 
detectors and gas detector installation instructions. 

Poison Prevention. In 1991, an estimated 133,500 children 
under the age of 5 were treated in hospital emergency rooms 
for accidental ingestions, chemical burns, and other acute in- 
juries associated with household substances. Accidental inges- 
tion accounted for a large percentage of these injuries. Data 
from NCHS show that 49 deaths in 1990 resulted from acci- 
dental ingestion of prescription drugs and hazardous house- 
hold chemicals. To reduce exposure of young children to haz- 
ardous household chemicals, CPSC proposed revisions to 
child-resistant packaging regulations to promote development 
ot effective package designs that are easier for all adults to use. 



In addition, CPSC conducted a study of aversive agents to de- 
termine their potential effectiveness in deterring the ingestion 
of household chemicals by young children and transmitted a 
report to the United States Congress in December 1992. This 
report advised against requiring the addition of potentially 
aversive agents to household products. 

Chronic Chemical Hazards. CPSC has focused recent at- 
tention on reducing consumer exposure to chemicals in paint 
products, pacifiers, school lab chemicals, heating equipment, 
and asbestos in the home. In 1987, CPSC issued a policy state- 
ment that it believes methylene chloride presents a carcino- 
genic risk and should be so labeled. Mediylene chloride, a sol- 
vent found in aerosol spray paints and chemical paint 
strippers, caused cancer in laboratory animals at levels in air 
similar to those that humans might encounter in the occa- 
sional use of those products without adequate ventilation. 
CPSC continues to monitor levels of carcinogenic ni- 
trosamines in rubber pacifiers and di(2-ethylhexyl)phthalate in 
vinyl pacifiers and teethers to minimize exposure to these 
chemicals. CPSC continues to be concerned about exposures 
of consumers to lead in paint. An information brochure has 
been distributed for consumer use and lead test kits are being 
evaluated. CPSC is also considering the need to lower the 
level of lead presently allowed in paint. CPSC has completed a 
laboratory study to determine the biological pollutants (aller- 
gens and pathogens) that consumers may be exposed to in the 
home from use of portable humidifiers. The laboratory study 
indicated that certain humidifiers, cool mist and ultrasonic, 
readily emit microorganisms from their reservoirs. CPSC has 
asked the American Home Appliance Manufactures (AHAM) 
to provide consumers with effective maintenance and cleaning 
instructions. CPSC is encouraging the kerosene heater indus- 
try, and the unvented gas space heater industry, to develop 
voluntary standards to limit emissions of toxic gases from 
these appliances. In response to numerous requests for guid- 
ance, CPSC has investigated levels of airborne asbestos fibers 
in homes that contained damaged or worn asbestos material. 
Airborne levels of asbestos were not found to exceed outdoor 
levels in the homes studied. CPSC issued guidelines and a def- 
inition of criteria for labeling products containing carcino- 
gens, reproductive or developmental toxicants, or neurotoxi- 
cants. This effort was part of die labeling of Hazardous Art 
Materials Act and the Federal Hazardous Substances Act. 
CPSC is currently studying emissions from wood stoves, car- 
pets, and carpet cushioning to ascertain if a hazard exists. In 
addition, CPSC is monitoring toxicity and exposure informa- 
tion on substitute formulations for methylene chloride paint 
strippers. 

Heat Tapes. Electric heat tapes are electric heaters in the 
form of tapes or cables. Different types of heat tape are manu- 
factured for a variety of users. They are plugged into outlet re- 
ceptacles and produce low levels of heat to prevent water from 
freezing in pipes, to melt slush and ice in gutters and down- 
spouts, and to prevent plants from freezing in gardens and 
greenhouses. The tapes used on water pipes are intended to be 
wrapped around the pipe or run along the length of the pipe 
and usually are covered with thermal insulation. In 1990, 
2,000 fires, 10 deaths, and 100 injuries were attributed to heat 
tape ignition. The fire estimates indicate that more than half 
of these fires occur in mobile homes, suggestive that the dam- 



^ 



Prevention '93/'94: Federal Programs and Progress 



age and injuries fall disproportionately on those with lower in- 
comes. As with all residential fires, the elderly, the disabled, 
and children are particularly vulnerable. A multi-year project 
is in progress to determine if these products pose an unreason- 
able risk of injury and to determine what measures might be 
effective to reduce the fire hazards associated with the use of 
these products. 

Buckets. Since January 1984, CPSC has received reports of 
213 bucket-related drownings and 25 non-fatal incidents. 
Most of the victims were children between 8 and 14 months 
of age. Of incidents where race was known, the majority in- 
volved members of minority groups. Most of the buckets 
were made from plastic and had a capacity of 5 gallons. Since 
1989, CPSC has been working with industry to address the 
drowning hazard presented by 5-gallon buckets. At the re- 
quest of the Commission, ASTM (formerly the American So- 
ciety for Testing and Materials) established Subcommittee 
F 15.31 on May 5, 1992. The subcommittee is developing a 
consensus standard for specification of cautionary labeling for 
5-gallon open head containers and is exploring the feasibility 
of a performance standard. The only existing legislation ad- 
dressing this problem is a California law requiring warning 
labels on all 5-gallon buckets sold in that State after Septem- 
ber 1, 1993. 

Infant Suffocation. Each year about 200 suffocation-re- 
lated deaths of infants under 1 year of age are reported to 



the National Center for Health Statistics. Some suffocation 
deaths may not be identified because they are diagnosed as 
Sudden Infant Death Syndrome (SIDS). SIDS is the official 
cause of death for about 6,000 infants each year. Since suf- 
focation and SIDS are typically indistinguishable at autopsy, 
some suffocation deaths may be diagnosed as SIDS. During 
the winter of 1989-1990, CPSC became aware of infant 
deaths associated with the use of infant bean bag cushions. 
As ofjuly 1992, 37 incidents had been identified; 35 of these 
resulted in death. Most of these deaths were diagnosed as 
SIDS although the infants were found with their faces down 
into the product. CPSC banned the cushions in June 1992. 
Based on its experience with the infant bean-bag cushions, 
CPSC recognized that other product-related infant suffoca- 
tive deaths may be missed. CPSC initiated the Infant Suffo- 
cation Project to identify products and product characteris- 
tics that may be involved in, or contribute to the suffocation 
of infants. 

Through FY 1994, CPSC investigators continue to conduct 
death scene investigations of infants who died from suspected 
SIDS or suffocation. When possible, the products on which 
infants died will be collected from parents or medical examin- 
ers, or identical products purchased for evaluation in CPSC 
laboratories. The information gathered from this study will be 
analyzed by CPSC staff to determine if the products and prod- 
uct characteristics contributed to the suffocation of infants. 
This information may assist the CPSC in developing potential 
remedial strategies. 



(ff) 



Chapter 



DHHS Prevention 




Inventory 



HP 

he tables that follow present a comprehensive 
profile of health promotion and disease preven- 
tion programs and activities within the Depart- 
^■^^» men i ii! I [ealth anil I hi in. in Sen ices. Together 

this inventory and the Chapter 3 narrative provide a composite of DHHS 
activities directed toward improving the general health of the American 
people. The inventory is organized into the 22 prevention priority areas 
of Healthy People 2000: National Health Promotion and Disease Prevention 
Objectives. The inventory includes programs of the Public Health Service, 
the Health Care Financing Administration, and the Administration for 
Children and Families. Resource levels are reported in detail for fiscal 
years 1992 and 1993. 



refe 



Prevention '93/'94: Federal Programs and Progress 



© 



DHHS Prevention Resources Inventory 



Table 1. Block Grant Resources, FY 1992 and 1993 



(Dollars in Thousands) 



Block Grant Resources 


FY 1992 

Actual 


FY 1 993 

Estimated 








Total Block Grant Funding 


$1,408,250 
134,511 


$1,408,250 
148,743 


Substance Abuse and Mental Health 
Services (ADMS) Block Grant 

Preventive Health Services Block Grant 1 

Maternal and Child Health (MCH) Services 
Block Grant 


649,564 


664,534 

440,871 

2,800,000 


Community Services Block Grant 2 
Social Services Block Grant 2 


435,207 
2,805,128 


Total, Block Grant Funding 


$5,432,660 


$5,462,398 


Funds Targeted to Prevention Activities 




226,102 

21,000 

299,000 


ADMS Block Grant 


201,698 


Preventive Health Services Block Grant 1 
MCH Services Block Grant 


21,000 
290,496 


Community Services Block Grant 2 


2 


Social Services Block Grant 2 


2 


2 


Total, Targeted to Prevention 


$513,194 


$536,102 


'Total funding for Preventive Health Services Block Grant is included on the assumption that all of these activities are prevention related 

but are not readily identifiable in any one category. 
2 For Community Services and Social Services Block Grants, funds specifically for health promotion and disease prevention activities are 

unknown. 



wD 



Prevention '93/'94: Federal Programs and Progress 



Table 2. Resources for Prevention Activities, by Agency, Department of Health 
and Human Services, FY 1992 and 1993 



® 



(Dollars in Thousands) 



FY 1992 FY 1993 
Agency Actual Estimated 




Public Health Service 




$49,939 
1,212,028 

331,050 
1.224,255 

717,087 
4,727,963 


Agency for Health Care Policy and Research 


$50,550 


Centers for Disease Control and Prevention 


1,111,784 


Food and Drug Administration 


319,956 


Health Resources and Services Administration 
Indian Health Service 
National Institutes of Health 


1,157,289 

673,376 

3,142,213 


Office of the Assistant Secretary for Health 

Substance Abuse and Mental Health 
Services Administration 


169,683 
897,312 


187,377 


1,052,150 
$9,501,849 


Subtotal, Public Health Service 


$7,000,663 


Health Care Financing Administration 


10,936,000 


13,304,000 


Administration for Children and Families 


413,698 


445,571 


Total Resources 


$20,350,361 


$23,251,420 



DHHS Prevention Resources Inventory 



Table 3. Resources for Prevention Activities, by HEALTHY PEOPLE 2000 Priority 
Area, Department of Health and Human Services, FY 1992 and 1993 



(Dollars in Thousands) 



r Areas 


FY 1992 
Actual 


FY 1993 

. Estimated 


1 . Physical Activity and Fitness 


$39,373 
147,551 


$37,488 

172,765 

22,081 

1,628,978 

804,748 

1,749,587 

69,878 

270,077 

58,110 

97,656 

401,235 

212,785 

1,038,649 

6,508,937 

182,172 

1,152,574 

1,180,986 

864,404 

114,518 

773,291 

775,551 

66,981 


2. Nutrition 


3- Tobacco 


19,826 


4 Alcohol and Other Drugs 


1,470,209 


5. Family Planning 


668,825 


6. Mental Health and Mental Disorders 


1,470,828 


7. Violent and Abusive Behavior 

8. Educational and Community-Based Programs 

9. Unintentional Injuries 


70,325 

257,935 

50,127 


10. Occupational Safety and Health 


96,605 


11. Environmental Health 


387,219 


12. Food and Drug Safety 


210,662 


13. Oral Health 


768,973 


14. Maternal and Infant Health 


5,824,679 


15. Heart Disease and Stroke 


180,144 


16. Cancer 

17. Diabetes and Chronic Disabling Conditions 

18. HIV Infection 


1,055,012 

1,126,101 

857,231 


19. Sexually Transmitted Diseases 


108,607 


20 Immunization and Infectious Diseases 


636,505 


21. Clinical Preventive Services 


707,644 


22. Surveillance and Data Systems 


63,480 


Total Resources 


$16,217,861 


$18,183,451 



© 



Prevention '93/'94: Federal Programs and Progress 



Table 4. Agencies Reporting Prevention Activities, by Healthy People 2000 Priority 
Area, Department of Health and Human Services, FY 1992 



(Dollars in Thousands) 



Agencies Reporting Prevention Activities 


1. 

Physical 

Activity 

and Fitness 


2. 

Nutrition 


3. 

Tobacco 


4. 

Alcohol 

and Other 

Drugs 


5. 

Family 
Planning 


Public Health Service 










Agency for Health Care Policy and Research 
Centers for Disease Control and Prevention 
Food and Drug Administration 
Health Resources and Services Administration 


$0 
447 


$0 
719 


$0 

7,343 



2,068 


$0 



6,500 


$0 





2,000 


7,205 
363 


7,980 


50.644 


Indian Health Service 











77,800 


1.500 


National Institutes of Health 


23,406 


136,729 
126 




18,812 





301,665 
500 

827,869 


172,696 
58,591 




Office of the Assistant Secretary for Health 

Substance Abuse and Mental Services 
Administration 


1,520 



Subtotal, Public Health Service 


$27,373 


$145,142 


$28,223 


$1,222,314 


$500,378 


Health Care Financing Administration 











202.000 


405,000 


Administration for Children and Families 


12,000 


94,097 





50.564 


+ 


Total Resources Reported 


$39,373 


$239,239 


$28,223 


$1,474,878 


$905,378 



Agencies Reporting Prevention Activities 


13. 

Oral 
Health 


14. 

Maternal 

and Infant 

Health 


15. 

Heart 

Disease 

and Stroke 


16. 

Cancer 


17. 

Diabetes 
and Chronic 

Disabling 
Conditions 


Public Health Service 










Agency for Health Care Policy and Research 
Centers for Disease Control and Prevention 
Food and Drug Administration 
Health Resources and Services Administration 


$1,440 

935 



25,782 

36,325 


$5,471 

6,696 



258.830 

308,875 

544,249 




$8,270 

99 





75 

207,978 




$4,008 

41,300 

10,000 

516 

6,750 

699.411 






$9,166 

24,925 



197,798 

6.500 

1,112,790 






Indian Health Service 


National Institutes of Health 


31,253 


Office of the Assistant Secretary for Health 





Substance Abuse and Mental Health 
Services Administration 





10,000 





Subtotal, Public Health Service 


$95,735 


$1,134,121 


$216,422 


$757,812 


$1,351,179 


Health Care Financing Administration 


627,000 


5,000,000 





295,000 





Administration for Children and Families 


46,238 


33 700 


1.350 


2.200 





Total Resources Reported 


$768,973 


$6,167,821 


$217,772 


$1,059,185 


$1,351,179 


+ 1 otal amount spent on prevention is not known. In 1 


'*'_. J i States pn>\ 


ided family plann 


ng services. 







^a 



DHHS Prevention Resources Inventory 



Table 4 (continued) 



(Dollars in Thousands) 



6. 

Mental 
Health and 

Mental 
Disorders 


7. 

Violent 

and Abusive 

Behavior 


8. 
Educational & 
Community- 
Based 
Programs 


9. 

Unintentional 
Injuries 


10. 

Occupational 

Safety and 

Health 


11. 

Environmental 
Health 


12. 

Food and 
Drug Safety 
















$0 

989 



4,613 

24,804 

59.044 



41,219 


$0 

14,678 



1,371 

2,696 

11,425 

4,910 




$0 
37,218 

31,849 
63,650 
48,953 
3,685 




$697 

17,147 



5,948 


$0 

69,011 



25,597 



1,997 




$0 

37,153 

3,899 

9,009 

108,000 

506,260 






$0 



205,050 






600 


29,013 



5.612 











$130,669 


$35,080 


$185,355 


$53,405 


$96,605 


$664,321 


$210,662 


1,338,000 





$1,259,000 














2,159 


36,869 


91,209 


6,932 





2,098 





$1,470,828 


$71,949 


$1,535,564 


$60,337 


$96,605 


$666,419 


$210,662 



18. 

HIV 
Infection 


19. 

Sexually 

Transmitted 

Diseases 


20. 

Immunization 

and 

Infectious 

Diseases 


21. 

Clinical 
Preventive 
Services 


22. 

Surveillance 
and Data 
Systems 


Total 
Resources 
Reported 














$8,148 

407,876 

72,302 

111,524 

3,170 

227,719 

1,287 

7,983 


$0 
85.652 



26,672 





$1,244 

311,812 

15,000 

18,000 

1,266 

127,015 






$12,106 




$0 

47,784 



6,760 

6,365 

59,271 




$50,550 
1,111,784 

319,956 
1,157,289 

673,376 
4,601,107 

189,289 

897,312 


396,637 

25,000 

146,295 

4,565 


10,241 





$840,009 


$112,324 


$474,337 


$594,844 


$120,180 


$ 9,000,663 








160,000 


255,000 





$10,936,000 


13,056 





21,226 








413,698 


$853,065 


$112,324 


$655,564 


$849,844 


$120,180 


$20,350,361 



ffp 



Prevention '93/'94: Federal Programs and Progress 



Table 5. Agencies Reporting Prevention Activities, by HEALTHY PEOPLE 2000 Priority 
Area, Department of Health and Human Services, FY 1993 (Estimated) 

(Dollars in Thousands) 



Agencies Reporting Prevention Activities 


1. 

Physical 

Activity 

and Fitness 


2. 

Nutrition 


3. 
Tobacco 


4. 

Alcohol 

and Other 

Drugs 


5. 

Family 
Planning 


Public Health Service 












Agency for Health Care Policy and Research 


$0 


$0 


$0 
10,300 


$0 


$0 


Centers for Disease Control and Prevention 


571 


622 








Food and Drug Administration 

Health Resources and Services Administration 



2,000 


7,250 





6,800 





333 


1,100 


8,544 


59,761 


Indian Health Service 











82,334 


2,277 
275,097 
172,696 




National Institutes of Health 


23,983 


142,151 
50 




29,966 





305,863 
500 

952,332 


Office of the Assistant Secretary for Health 

Substance Abuse and Mental Services 
Administration 


1,510 



Subtotal, Public Health Service 


$28,064 


$150,406 


$41,366 


$1,356,373 


$509,831 


Health Care Financing Administration 











232,000 


510,000 


Administration for Children and Families 


9,424 


116,965 





47,005 


+ 


Total Resources Reported 


$37,488 


$267,371 


$41,366 


$1,635,378 


$1,019,831 



Agencies Reporting Prevention Activities 


13. 

Oral 
Health 


14. 

Maternal 

and Infant 

Health 


15. 

Heart 

Disease 

and Stroke 


16. 
Cancer 


17. 

Diabetes 
and Chronic 

Disabling 
Conditions 


Public Health Service 












Agency for Health Care Policy and Research 
Centers for Disease Control and Prevention 


$1,357 


$782 


$7,570 
100 


$3,884 
60.500 


$8,339 
29,539 


730 


6,690 


Food and Drug Administration 











10.000 





Health Resources and Services Administration 
Indian Health Service 


29,100 
36,925 


281,001 
333,625 




75 

211,977 




511 

6.750 

708,029 


201,643 

6.700 
1,166.965 


National Institutes of Health 


31,235 


554,644 


Office of the Assistant Secretary for Health 

Substance Abuse and Mental Health Services 
Administration 

















48,638 











Subtotal, Public Health Service 


$99,347 


$1,225,380 


$219,722 


$789,674 


$1,413,186 


Health Care Financing Administration 


881,000 


5,600,000 





365.000 





Administration for Children and Families 


58.302 


34,948 


1.350 







Total Resources Reported 


$1,038,649 


$6,860,328 


$221,072 


$1,156,874 


$1,413,186 


+ Total amount spent on prevention is not known. In ] 


992, 23 States pr< 


ivided family plant 


ling services. 







Utf 



DHHS Prevention Resources Inventory 



Table 5 (continued) 



(Dollars in Thousands) 



6. 7. 8. 9. in I 19: ' 


Mental 
Health and 

Mental 
Disorders 


Violent 

and Abusive 

Behavior 


Educational & 
Community- 
Based 
Programs 


Unintentional 
Injuries 


Occupational 

Safety and 

Health 


Environmental 
Health 


Food and 
Drug Safety 














$0 

724 



4,618 

25,987 

61,737 




$0 

14,715 



1,291 

2,909 

11,360 

4,910 




$0 
37,182 

31,084 
69,023 
58,966 
4,413 




$791 

20,001 



8,070 

2,100 

27,102 




$0 

70,011 



25,597 



2,048 




SO 

44,984 

5,000 

10,606 

111,000 


$0 



207,100 






523,282 






5,685 





32,836 








$125,902 


$35,185 


$200,668 


$58,064 


$97,656 


$694,872 


$212,785 


3,392,000 





1,849,000 














1,685 


36,393 


90,964 


7,466 





2,300 





$3,519,587 


$71,578 


$2,140,632 


$65,530 


$97,656 


$697,172 


$212,785 



18. 

HIV 
Infection 


19. 

Sexually 

Transmitted 

Diseases 


20. 

Immunization 

and 

Infectious 

Diseases 


21. 

Clinical 
Preventive 
Services 


22. 

Surveillance 
and Data 
Systems 


Total 
Resources 
Reported 














$4,979 


$0 


$1,176 


$21,061 


$0 


$49,939 


410,927 


37,137 


416,365 





50,930 


1,212,028 


72,500 





22,400 








331,050 


118.854 





18,000 


415,498 


6,644 


1,224,255 


3,303 





1,287 


26,092 


6,700 


717,087 


231,280 


27,862 


118,857 


149,367 


60,507 


4,727,963 


100 








3,198 





187,377 


7,809 








10,535 





1,052,150 


$849,752 


$ 64,999 


$578,085 


$625,751 


$124,781 


$9,501,849 








180,000 


295,000 





13,304,000 


13,563 





23,006 








445,571 


$863,315 


$64,999 


$781,091 


$920,751 


$124,781 


$23,251,420 



fffj 



Prevention '93/'94: Federal Programs and Progress 



Table 6. Prevention Inventories, by HEALTHY PEOPLE 2000 Priority Area and 
Agency, Department of Health and Human Services, FY 1992 and 1993 







(Dollars in " 


fhousands) 






FY 1992 
Actual 


FY 1993 

Estimated 


1. Physical Activity and fitness 


Centers for 
Disease Control 
and Prevention 


National Center for Chronic Disease 
Prevention and Health Promotion 

Heart Beat— The Rhythm of Health 


$32 


so 

15 


Physical Activity Contact Network 


15 


Physician Assessment and Counseling for Exercise 

State-Based Physical Activity and Cardiovascular 
Disease Prevention Programs 


175 





225 


556 


Health Resources 
and Services 
Administration 


Maternal and Child Health Bureau 

Maternal and Child Health Block Grant 


2,000 


2,000 


National Institutes 
of Health 


National Center for Research Resources 

Physical Activity and Fitness Prevention Research 






1,008 


990 


National Heart, Lung, and Blood Institute 




295 


Obesity Education Initiative 


250 


Research on Effects of Physical Activity on 
Cardiovascular and Pulmonary Health 


10,690 


10,875 


National Institute on Aging 






Physical Activity and Fitness 


11.042 


11,373 


National Institute for Nursing Research 

Research on Physical Activity and Fitness 


416 


450 


Office of the 
Assistant 
Secretary for 
Health 


President's Council on Physical Fitness 
and Sports 






Media Communication Campaigns 


115 


110 
1,400 




Ten-Point National Program 


1,400 


Visits by Chairman of President's Council of 
Physical Fitness and Sports to All 50 States 


5 


Administration for 
Children and 
Families 


Office of Community Services 




9.424 


National Youth Sports Program 


12,000 




Total 


$39,373 


$37,488 



I fg 



DHHS Prevention Resources Inventory 



Table 6 (continued) 







(Dollars in Thousands) 


2. Nutrition 




FY 1992 

Actual 


FY 1993 | 

Estimated 


Centers for 
Disease Control 
and Prevention 


National Center for Chronic Disease 
Prevention and Health Promotion 

Food Industry Partnerships 

Prevention of Overweight and Consequences of 
Voluntary Weight Loss 

School-Based Nutrition Education 


$54 

271 
230 

164 




$55 

276 
31 


State-Based Dietary Surveillance for Chronic 
Disease Prevention 


260 


Food and Drug 
Administration 


Center for Food Safety and Applied Nutrition 

Food Labeling Initiative 


6,500 


6,500 


Food Label and Package Survey 


464 


516 


Health and Diet Survey 
Weight Loss Study 


106 
135 


100 
134 


Health Resources 
and Services 
Administration 


Bureau of Health Professions 






Health Professions Training and Education 


363 


333 


National Institutes 
of Health 


Fogarty International Center 






Vascular Biology in Health and Disease 


56 


58 


National Center for Research Resources 

Nutrition Prevention Research 


11,997 


11,774 


National Heart, Lung, and Blood Institute 

Cardiovascular Disease Nutrition Education Programs 
for Adults with Low Literacy Skills: Request for 
Applications 






1,869 


1,800 

970 
2,117 

3,197 
1,396 

4,528 

460 


Dietary Intervention Study in Children with High 
Cholesterol Levels 

Growth and Health Study — Girlhood Obesity 


2,018 
2,285 


Multicenter Studies of Diet and Liproproteins: 
Effects on Atherogenesis 


1,950 
1,248 

3,470 

410 


National Cholesterol Education Program 

Trials of Hypertension Prevention: Weight Loss and 
Sodium Restriction 


Women's Health Trial: Effect of Low-Fat Diet on 
Post-Menopausal Heart Disease 


National Institute on Aging 

Consumption of Foods Containing Complex 
Carbohydrates and Dietary Fiber* 


2,000 


2,160 



® 



Prevention '93/'94: Federal Programs and Progress 



Table 6 (continued) 



(Dollars in Thousands) 



2. Nutrition (cont.) 




FY 1992 
Actual 


FY 1993 
Estimated 


National Institutes 
of Health (cont.) 


National Institute on Aging (cont.) 

Effects of Dietary Fats/Lipids on Organ Function 
and Chronic Disease Development* 

Prevention and Treatment of Obesity* 


8,240 
6,180 




8,899 

6,674 


National Institute of Arthritis and 
Musculoskeletal Skin Diseases 

Role of Calcium in the Etiology and Prevention 
of Osteoporosis 






1,525 


1,592 


National Institute of Deafness and Other 
Communication Disorders 

Salt and Sodium Intake* 


108 


112 


National Institute of Diabetes and 
Digestive and Kidney Diseases 






Obesity and Exercise Research 


31 


32 


Other Nutrition Research 


44 


45 


National Institute on Drug Abuse 

Nutrition Prevention Research 


900 


1,000 


National Institute of Mental Health 






Eating Disorders Research 


650 


671 


National Institute of Neurological Disorders 
and Stroke 

Prevention and Treatment of Obesity* 


60 


60 


Office of the 
Assistant 
Secretary for 
Health 


Office of Disease Prevention and 
Health Promotion 

Dietary Guidelines for Americans 

Secretary's Healthy Menu Program 


72 
54 




50 


Administration for 
Children and 
Families 


Administration on Children, Youth, and 
Families 

Head Start 


88,072 


1 1 1 ,052 


Office of Community Services 

Community Food and Nutrition 
Migrants and Seasonal Farmworkers 


3,000 
3,025 


2.966 
2.947 




Total 


$147,551 


$172,765 


'Program is Funded by more 


than one institute. 







© 



DHHS Prevention Resources Inventory 



Table 6 (continued) 



(Dollars in Thousands) 



FY 1992 . FY 1993 
3. Tobacco .Actual Estimated , 


Centers for 
Disease Control 
and Prevention 


National Center for Chronic Disease 
Prevention and Health Promotion 






Reduction of Tobacco Use 


$7,343 


$10,300 


Health Resources 
and Services 
Administration 


Bureau of Primary Health Care 






Oral Cancer Screening and Anti-Tobacco Counseling 


100 


100 


Maternal and Child Health Bureau 

Grants for Projects to Decrease Substance Abuse 


1,468 




500 


Reducing Risk Behavior Among Adolescents 
and Young Women 


500 


500 


National Institutes 
of Health 


National Center for Research Resources 
Tobacco Use Prevention Research 


100 




100 


National Heart, Lung, and Blood Institute 

Lung Health Study: Effect of Special Care on Pulmonary 
Function of Smokers 

Other Research Programs Related to Smoking and 
Health 

Smoking Education Program 






5,248 

2,000 
223 


5,248 

2,048 
205 


National Institute of Dental Research 






Smokeless Tobacco Use 





100 


National Institute on Drug Abuse 




2,000 


Tobacco Prevention Research 


1,900 


National Institute of Nursing Research 
Research on Smoking Behavior 


231 


250 


National Institute on Aging 






Tobacco 


713 


730 




Total 


$19,826 


$22,081 



^^ 



Prevention '93/'94: Federal Programs and Progress 



Table 6 (continued) 







(Dollars in Thousands) 


4. Alcohol and Other Drugs 


FY 1992 
Actual 


FY 1993 
Estimated 


Food and Drug 
Administration 


Office of Regulatory Affairs 

Monitoring of Substance Abuse 






$6,500 


$6,800 


Health Resources 
and Services 
Administration 


Bureau of Primary Health Care 




8.420 


Health Care for the Homeless Program 


7,845 


Bureau of Health Professions 

Health Professions Training and Education 


135 


124 


Indian Health 
Service 


American Indian Anti-Drug Abuse Activities 


77,800 


82,334 


National Institutes 
of Health 


Fogarty International Center 

Alcohol and Other Drugs Prevention Research 


102 


105 


National Center for Research Resources 

Alcohol and Other Drugs Prevention Research 


404 


100 


National Heart, Lung, and Blood Institute 

Prevention and Treatment of Hypertension Study (PATHS): 
Trial of Alcohol Restriction in the Treatment of Mild 
Hypertension 






564 


585 


Other Research Related to Alcohol and Heart Disease 


932 


945 


National Institute on Aging 






Alcohol and Other Drugs 


3,364 


3,465 


National Institute on Alcohol Abuse and 
Alcoholism 






AIDS and HIV Infections 


1,940 


2.000 

100 

2,000 


Advertising/Media 

Alcohol-Related Problems Among Special Populations 


90 
3,145 


Alcohol and Violence 





379 


Community-Based Research 


3,871 


3.856 


Deterring Drinking and Driving 


3,562 


3,010 


Economic Aspects of Prevention 


428 


853 


Effects of Alcohol Warning Labels 


1,239 


1,400 


Prevention of Alcohol Abuse Among Youth 


3,945 


2,100 


Prevention Issues in the Workplace 


1,806 


1,200 


Prevention Research Center 


1,515 


1.635 


Primary Care 


560 


335 


Psycho-biologic Issues 


2.486 


1,920 


Small Business Innovation Research 


' -: 



ffffr 



DHHS Prevention Resources Inventory 



Table 6 (continued) 







(Dollars in ' 


Thousands) 


4. Alcohol and Other Drugs (cont.) 


FY 1992; 
Actual 


FY 1993 

Estimated : 


National Institutes 
of Health (cont.) 


National Institute on Drug Abuse 




12,400 

49,800 

94,300 

4,300 


Alcohol and Other Drug Abuse 


11,659 
46,326 


Early Interventions 


Special Populations 


93,221 


Treatment Outcome Research' 


4,299 




Maternal Drug Abuse Amelioration 


44,257 


45,200 


Neuroscience Research 


60,128 


60,200 
1,700 
2,900 


Workplace Drug Abuse Policy 


1,698 


Workplace Program 


2,867 


National institute of Mental Health 








Research on Prevention of Comorbid Mental Disorders 








and Substance Abuse 


1,550 


1,840 


Office of the 


Office of Population Affairs 






Assistant 
Secretary for 


Family Planning Substance Abuse Training 


500 


500 


Health 








Substance Abuse 


Center for Substance Abuse Prevention 






and Mental Health 

Services 

Administration 


Communication Cooperative Agreement 


3,055 


848 
105,063 


Community Partnerships 


98,786 




Community Youth Activity Program for High-Risk Youth 


9,907 







Conference Grant Program 


12,081 


2,094 

56,295 

4,701 


High-Risk Youth Program 


57,874 


Media and Communication Campaigns 


3,363 




National Clearinghouse for Alcohol and Drug 








Information (NCADI) 


5,036 


4,172 




Pregnant and Postpartum Women and Their Infants 








Program 


52,631 


50,307 




Residential Women/Children Program 


10,000 


*, 


Substance Abuse Prevention Training (SAPT) 


15,088 


14,598 


Training for Prevention and Treatment Providers 


5,561 


Center for Substance Abuse Treatment 




11,337 
226,102 

15,300 
220,110 


Activity Program for Disadvantaged Youth 


10,932 


ADMS Block Grant 


201,698 


Capacity Expansion Program 


9,000 


Drug Treatment Programs 


165,902 



© 



Prevention '93/'94: Federal Programs and Progress 



Table 6 (continued) 



(Dollars in Thousands) 



FY 1992 FY 1993 
4. Alcohol and Other Drugs (cont.) Actual Estimated 


Substance Abuse 
and Mental Health 
Services 
Administration 
(cont.) 


Center for Substance Abuse Treatment (cont.) 

Drug Treatment Programs in Campus Settings 


17,988 


18,395 


Family Planning Substance Abuse Training 


500 


500 


Improved Drug Treatment Initiatives 


130,032 


178,215 



Primary Care Provider/Substance Abuse Linkage 
Initiative 


216 


SAPT Block Grant 


2,300 


1 1 ,305 
32,990 


Treatment in Criminal Justice Settings 


15,919 


Administration for 
Children and 
Families 


Administration on Children, Youth, and 
Families 






Child Abuse and Neglect: 






Discretionary Grants 


1,417 


1,417 
19,039 


Emergency Prevention 


19,518 


Runaway and Homeless Youth 

Drug Prevention 


15,286 


14,602 


Youth Gang Drug Abuse Prevention Programs 


10,943 


10,647 


Office of Policy and Evaluation 






Social Services Research Discretionary Grants 


100 





Administration for Native Americans 






National Native American Youth Alcohol, Drug, and 
Smoking Prevention Initiative 


250 


250 


Office of Community Services 






Social Services Block Grant 


+ 


+ 


National Youth Sports Program 


3,000 


1,000++ 


Administration on Developmental Disabilities 

Prevention of Fetal Alcohol Syndrome 


50 


50 


Health Care 

Financing 

Administration 


Medicaid 
Medicare 


142,000 
60,000 


162,000 
70,000 




Total 


$1,470,209 


$1,628,978 


* Program is funded by more than one institute. 
"These programs were transferred to CSAT for treatment programs. 

+ Total amount spent in preventive category is not known. In FY 1992, 1- States provided substance abuse services. 
++ Total amount spent in preventive category is not known. FY 1993 funds are estimated; the $.' million in FY1992 represented a one-time 
only appropriation used lor substance abuse prevention. 



© 



DHHS Prevention Resources Inventory 



Table 6 (continued) 



{Dollars in Thousands) 



FY 1992 FY 1993 
5. Family Planning Actual Estimated 


Health Resources 
and Services 
Administration 


Bureau of Primary Health Care 

Family Planning Services with Primary Care 


$48,000 


$57,000 


Bureau of Health Professions 

Health Professions Training and Education 


264 


261 


Maternal and Child Health Bureau 




2,500 


Adolescent Training Grants 


2,380 


Indian Health 
Service 


Fetal Alcohol Syndrome Among Americans Indians 


1,500 


2,277 


National Institutes 
of Health 


National Center for Research Resources 

Family Planning Prevention Research 




3,958 


4,033 


National Institute of Child Health and 
Human Development 

Reproductive Health 


54,558 


56,056 


Office of the 
Assistant 
Secretary for 
Health 


Office of Population Affairs 






Adolescent Family Life "CARE" Demonstration Projects 

Adolescent Family Life "Prevention" Demonstration 
Projects 

Adolescent Family Life Research 


3,190 

1,986 
1,003 


3,059 

2,018 
994 


Family Planning General Training Program 


2,230 


2,565 

160,000 

175 

1,408 



2,477 




Family Planning Services Program 


139,162 


Family Planning Information Exchange 
Family Planning Nurse Practitioner Training Program 
Family Planning Nurse Practitioner Accreditation Project 
Family Planning Research 


167 

1,250 

11 


1,090 


Family Planning STD/HIV Training* 


3,001 


Administration for 
Children and 
Families 


Office of Community Services 






Social Services Block Grant 


+ 


+ 


Health Care 

Financing 

Administration 


Medicaid 


405,000 


510,000 




Total 


$668,825 


$804,748 


*Most of the earmarked funds in this category are from cooperative agreements with CDC and SAMHSA. 

+Total amount spent on prevention category is not known. In FY 19 Q 2, 23 States provided family planning services. 



ffi^ 



p 


ievention '93/'94: Federal Programs and Progress 










Table 6 (continued) 


(Dollars in 


Thousands) 






6. Mental Health and Mental Disorders 


FY 1992 
Actual 


FY 1993 
Estimated 




Centers for 
Disease Control 
and Prevention 


National Center for Injury Prevention 
and Control 






Case Control Study of Attempted Suicide 


$300 


$200 


National Electronic Injury Surveillance System 
Resource Guide on Youth Suicide Prevention Programs 
Screening Program for Suicide Risk in Adolescents 


50 


100 


20 
219 



228 


Sentinel Injury Surveillance System 


400 


196 


Health Resources 
and Services 
Administration 


Bureau of Primary Health Care 

Health Care for the Homeless Program 






3.908 


3,932 


Bureau of Health Professions 

Health Professions Training and Education 


705 




686 


Indian Health 
Service 


Direct and Indirect Mental Health Services 


24,804 


25,987 


National Institutes 
of Health 


National Center for Nursing Research 

Research on Promotion of Mental Health 


219 


240 


National Center for Research Resources 

Mental Health and Mental Disorders Prevention Research 






2,016 


1.979 


National Heart, Lung, and Blood Institute 






Psychophysiological Investigations of Myocardial 
Ischemia 


1,400 


1,400 


Other Stress Reduction Research and Demonstration 
Programs 


8,000 


8,192 


National Institute on Alcohol Abuse and 
Alcoholism 






Case Study of Attempted Suicide 


100 


75 


National Institute of Mental Health 






Clinical Epidemiologic and Prevention Research on 
Suicide 


852 


880 


Research on Prevention of Child and Adolescent 
Disorders 


6,672 


6,866 


Research on Prevention of Depressive/Anxiety Disorders 
Research on Prevention of Severe Mental Disorders 


11,959 
2,727 


12,363 
2,819 


Enhancing Health Through Stress Related/Behavioral 
Research 


3,043 


3,146 

3.559 
14,250 


Research on Organization and Delivery of Services to 
Prevent Mental Disorders/Promote Mental Health 

Other Prevention Research 


2,496 
13,778 



@ 



DHHS Prevention Resources Inventory 



Table 6 (continued) 



(Dollars in Thousands) 



FY 1992 FY 1993 
6. Mental Health and Mental Disorders (cont.) Actual Estimated 


National Institutes 
of Health (cont.) 


National Institute of Neurological Disorders 
and Stroke 


5,782 




Understanding the Human Brain 


5,968 


Substance Abuse 
and Mental Health 
Services 
Administration 


Center for Mental Health Services 

Community Support Program 

Clinical Training 

Projects for Assistance in Transition from Homelessness 

AIDS Training 


3,940 

1,801 

30,000 

5,478 


2,883 

491 

29,462 




Health Care 

Financing 

Administration 


Medicaid 


1,300,000 
38,000 


1,577,000 
45,000 


Medicare 


Administration for 
Children and 
Families 


Administration on Children, Youth, and Families 

Child Abuse and Neglect Discretionary Program: 
Psychological Impact of Child Maltreatment 


1,709 


1,185 


Office of Community Services 




+ 


Social Services Block Grant 


+ 


Office of Refugee Resettlement 

Targeted Assistance 450 500 




Total $1,470,828 


$1,749,387 


+Total amount spent on prevention category not known. In FY 1992, 23 States provided counseling and mental health services. 



^p 



Prevention '93/'94: Federal Programs and Progress 



Table 6 (continued) 



(Dollars in Thousands) 





FY 1992 


FY 1993 


7. Violent and Abusive Behavior 


Actual lstimated 


Centers for 
Disease Control 
and Prevention 


National Center for Chronic 

Disease Prevention and Health Promotion 






Sex Offenses Program 


$5,000 


$5,500 


School Health Survey 


30 


600 

2,300 


Youth Risk Behavior Survey 


2,250 


National Center for Injury Prevention 
and Control 






Case Control Study of Attempted Suicide 


325 


300 


Criminal History as a Predictor of Criminal Activity 

Current Adolescent Violence Prevention Curricula 

Community-Based Youth Violence 
Prevention Demonstration Projects 


197 





200 
1,200 


15 
1,100 


Epidemiology and Cost of Firearms 





272 


Estimating the Injury Prevention Effects 
of Criminal Justice Intervention 

Investigation of Children as Witnesses to Urban Violence 

State and Community-Based Injury Control Programs 

Youth Violence in Minority Communities 


180 


189 

229 

4,200 

10 


220 

5,000 

76 


Indian Health 
Service 


Direct/Indirect Mental Health Services 


2,696 


2,909 


Health Resources 
and Services 
Administration 


Maternal and Child Health Bureau 




500 


Maternal and Infant Health 


777 


Adolescent Violence Prevention Project 


132 


140 


Children's Community Bridge 


166 


166 


PACT for Alternatives to Violence and Abuse 


146 


150 


Positive Emotional Capacity Enhancement 
(PECE) Training 


150 


150 
185 


Adolescent Violence Prevention Resource Center 





National Institutes 
of Health 


National Center for Research Resources 

Violent and Abusive Behavior Prevention Research 


100 


100 


National Heart, Lung, and Blood Institute 

Effects of Cholesterol and Fat Reduction on Behavior 


327 


393 


National Institute of Nursing Research 

Research in Violence and Abuse-Parents Children 


468 


500 



© 



DHHS Prevention Resources Inventory 



Table 6 (continued) 



(Dollars in Thousands) 





FY 1992 


FY 1993 


7. Violent and Abusive Behavior (cont.) 


Actual . Estimated 


National Institutes 
of Health (cont.) 


National Institute on Aging 

Violent and Abusive Behavior 


284 




290 


National Institute on Alcohol Abuse 
and Alcoholism 


200 
700 




Heavy Drinking and Marital Violence in Newlyweds 
Hispanic Drinking and Intrafamily Violence 





171 


National Institute on Drug Abuse 

Violence Prevention Research 


5,300 


5,700 


National Institute of Mental Health 

Research on Risk Factors and Prevention of Violence, 
Crime, and Delinquency and Their Sequelae 


2,422 


2,506 


Office of the 
Assistant 
Secretary for 
Health 


Office of Minority Health 

Community Coalitions To Support Health and Human 
Services (Minority Males in Crisis) 






4,910 


4,910 


Administration for 
Children and 
Families 


Administration on Children, Youth, and Families 

Basic and Medical Neglect State Grants 


20,518 


20,354 

814 
9,325 
5,270 


Child Abuse and Neglect Evaluations of Treatment 
Approaches 


1,299 


Children Justice Act State Grants 

Child Abuse: Community-Based Prevention State Grants 


9,325 
5,367 


Administration on Developmental Disabilities 

Positive Behavior Management 


360 


630 


Office of Community Services 






Social Services Block Grant 


+ 


+ 




Total 


$70,325 


$69,878 


+Total amount spent on prevention category not known; in FY 1992, 50 States provided protective services to abused and neglected children 
and 36 States provided protective services to adults, including victims of family violence. 



© 



Prevention '93/'94: Federal Programs and Progress 



Table 6 (continued) 



(Dollars in Thousands) 



FY 1992 FY 1993 
8. Educational and Community-Based Programs Actual Estimated 


Centers for 
Disease Control 
and Prevention 


National AIDS Information and 
Education Program 


$6,768 


$6,732 


National Partnership Programs 


National Center for Chronic Disease 
Prevention and Health Promotion 






Community Health Promotion and Disease Prevention 

Preventive Health and Health Services Block 
Grant 


150 

21,000 


150 


21.000 


Public Health Practice Program Office 






Health Professions Training and Education* 


9,000 


9.000 


Implementation of Healthy Communities 2000 


300 


300 


Health Resources 
and Services 
Administration 


Bureau of Health Professions 

Health Professions (Nurses) Training and Education 






12,267 


12,271 


Health Professions (Public Health Professionals) 
Training and Education 


3.382 


2.513 


Bureau of Primary Health Care 






Federal Employer Occupational Health 


8,200 


8,300 


Maternal and Child Health Bureau 

Maternal and Child Health Block Grant 




8.000 


8,000 


Indian Health 
Service 


Health Education 

Community Health Representatives 

Public Health Nursing 


6,300 
39,000 
18,350 


7.673 
41.040 


20.310 


National Institutes 
of Health 


National Center for Research Resources 

Educational and Community-Based Programs 


1,008 


990 


National Heart, Lung, and Blood Institute 

Atherosclerosis Risk in Communities Study 
National Blood Resources Education Program 


5,331 
1.097 


12.485 
686 


National Institute of Child Health 
and Human Development 




14.000 


Educational and Community-Based Programs 


13,700 


National Institute of Diabetes and Digestive 
and Kidney Diseases 




49 


Educational and Community-Based Programs 


48 


National Institute of Mental Health 




187 


Public Information and Education: Prevention of 
Mental Disorders 


148 



Go 



DHHS Prevention Resources Inventory 



Table 6 (continued) 



(Dollars in Thousands) 



FY 1992 FY 1 993 I 
8. Educational and Community-Based Programs (cont.) Actual Estimated 


National Institutes 
of Health (cont.) 


National Institute of Nursing Research 

Exploratory Centers for Health and Behavior Research 
Educational and Community-Based Programs 






300 
479 


330 
500 


National Institute on Aging 

Alzheimer's Disease Education/Referral Center 
Alzheimer's Disease Community Outreach 


900 
853 


783 
857 


National Library of Medicine 

National Library of Medicine Outreach Program 


6,460 


6,544 


Office of the 
Assistant 
Secretary for 
Health 


Office of Disease Prevention and 
Health Promotion 






Market Research on Health Communication With 
Hard-to-Reach Youth 


3 


13 




Healthy People 2000 Consortium Planning 


200 


National Health Promotion Program 


2 


ODPHP National Information Health Center 


487 


1,200 


School Health Support 


100 





Worksite Health Promotion Support 


100 





Office of Minority Health 




3,200 


Minority Community Health Coalition 


2,793 


Administration for 
Children and 
Families 


Administration on Children, Youth, and Families 

Challenge Grant Program (Child Abuse Prevention) 

Child Abuse and Neglect State Grants Evaluation of 
Community-Based Prevention of Child Maltreatment 


5,367 
300 


5,270 
300 


Community-Based Prevention Demonstrations 


1,699 


1,800 


Administration on Developmental Disabilities 

Basic State Grant Program 


67,706 


67,372 
16,125 

97 


University Affiliated Facilities 


16,030 

107 


Minority Health (Native American/Hispanic) and 
Cultural Diversity 




Total 


$257,935 


$270,077 


This program is jointly funded by CDC and HRSA. 



ral 



Prevention '93/'94: Federal Programs and Progress 



Table 6 (continued) 



(Dollars in Thousands) 



FY 1992 FY 1993 
9. Unintentional Injuries Actual Estimated 


Agency for Health 
Care Policy and 
Research 


Major Trauma Outcome 


$697 


$791 


Centers for 
Disease Control 
and Prevention 


National Center for Injury Prevention 
and Control 






Emergency Medical Services 


1 


1 


Injury Control Program 


10,993 


14,766 


National Electronic Injury Surveillance System 
Second World Conference on Injury Control 


125 


100 


205 


100 

4.200 

800 


State and Community-Based Injury Control Programs 


5,032 


State Injury Grantees 


786 


Unintentional Injuries Evaluation 


5 


34 


Health Resources 
and Services and 
Administration 


Maternal and Child Health Bureau 

Childhood Injury Grants 


1,096 


3,260 


Emergency Medical Services for Children 


4.852 


4,810 


Indian Health 
Service 


American Indian Injury Prevention Program Activities 


600 


2.100 


National Institutes 
of Health 


National Center for Research Resources 

Unintentional Injury Prevention Research 


100 


100 


National Institute of Arthritis and 
Musculoskeletal and Skin 

Hip Fractures Due to Osteoporosis 






50 


52 

42 


Sports Injuries 


40 


National Institute of Dental Research 

Research on Orofacial Trauma 





71 


National Institute on Drug Abuse 

Unintentional Injuries 




3,700 


3.400 


National Institute of Mental Health 

Mental Health Aspects of Prevention of Accidents and 
Unintentional Injuries 






173 


179 


National Institute of Neurological Disorders 
and Stroke 

Head and Spinal Cord Injury 


9.559 


9,867 



vm 



DHHS Prevention Resources Inventory 



Table 6 (continued) 



(Dollars in Thousands) 



FY 1992 FY 1993 
9. Unintentional Injuries (cont.) Actual Estimated 


National Institutes 
of Health (cont.) 


National Institute of Nursing Research 

Prevention of Falls 


121 




150 


National Institute on Aging 

Unintentional Injuries 5,360 


5,521 


Administration for 
Children and 
Families 


Administration for Children, Youth, and Families 

Challenge Grant Program 


4,933 


5,366 

300 
1,800 


Child Abuse and Neglect State Grants Evaluation of 
Community-Based Prevention of Child Maltreatment 

Community-Based Prevention Demonstrations 


300 
1,699 


Office of Community Services 


+ 




Social Services Block Grant 


+ 




Total 


$50,127 


$58,110 


+The total amount spent on prevention category is not known. 



Uri# 



Prevention '93/'94: Federal Programs and Progress 



Table 6 (continued) 







(Dollars in 


Thousands) 


1 0. Occupational Safety and Health 


FY 1992 

Actual 


FY 1993 
Estimated 


Centers for 
Disease Control 
and Prevention 


National Institute for Occupational Safety 
and Health 




$25,000 

250 

250 

4,000 


Agricultural Safety and Health 


$25,000 


Alaska Field Station 


250 


Carpal Tunnel Syndrome Among Meatpackers 
Construction Safety and Health 


250 
2,500 


Cumulative Trauma Disorders 


750 


750 
350 
250 


Elevated Blood Lead Levels 


350 


Energy-Rated Research 


250 


Healthy People 2000 OSH Work Group 


50 


50 
250 
250 
250 
250 
750 


Mortality Industry and Occupation Coding 


250 


National Coal Workers Autopsy Study 


250 


National Occupational Health Survey of Mining 

National Traumatic Occupational Fatalities Database 

Noise-Induced Hearing Loss 

Occupational and Environmental Medicine Training 
Primary Care Physician* 

Occupational^ Exposed Hepatitis B 

Occupational Fatality Surveillance 


250 


250 


750 


236 


236 

250 

725 

50 


250 


725 


Occupational Homicides 


50 


Occupational Skin Disorders 


250 
7,500 


250 
7,500 
2,000 

250 


Respiratory Diseases 


SENSOR 


2,500 


Small Business 


250 


State-Based Activities in Occupational Health and Safety 
State Occupational Safety and Health Plan 


25,000 
250 


25.000 

250 

50 


Surveillance of Health Care Workers 

Worksite Back Injury Programs 

Worksites with Mandated Employee Use of Occupant 
Protection Systems 


50 


250 


250 

50 
250 
250 


50 


Worksite Programs 
Work-Related Stress 


250 
250 



fff} 



DHHS Prevention Resources Inventory 



Table 6 (continued) 



(Dollars in Thousands) 



FY 1992 FY 1993 i 
10. Occupational Safety and Health (cont.) Actual Estimated 


Health Resources 
and Services 
Administration 


Bureau of Health Professions 

Health Professions Training and Education in 
Occupational Health 


147 




147 


Bureau of Primary Health Care 

Federal Employee Occupational Health Programs 






25,000 


25,000 


Office of Rural Health Policy 


450 


450 


Rural Research Center Program 


National Institutes 
of Health 


National Center for Research Resources 

Occupational Safety and Health Research 


100 


100 


National Institute of Allergy 
and Infectious Diseases 




1,183 
172 


Occupational Lung Disease 
Tuberculosis-Health Care Workers 


1,160 
165 


National Institute of Deafness 

and Other Communication Disorders 

Noise-Induced Hearing Loss 




544 


523 


National Institute of Dental Research 

Research on Occupational Safety 
and Health in Dentistry 


49 


49 




Total $96,605 


$97,656 



Ual 



Prevention '93/'94: Federal Programs and Progress 



Table 6 (continued) 



(Dollars in Thousands) 



FY 1992 FY 1993 
1 1 . Environmental Health Actual Estimated 


Agency for Toxic 
Substances and 
Disease Registry 


Division of Health Education 






Environmental Health Education 


$650 


$600 


Provider Training Related to 

Hazardous Substance Exposure 


200 


200 
5,000 


Risk Assessment Programs for State Health Agencies 


5,300 


Division of Health Studies 




500 


Emergency Response Programs 

Relationship Between Hazardous Substance Exposure 
and Human Uptake 


700 


5,500 


5,500 


Centers for 
Disease Control 
and Prevention 


National Center for Environmental Health 

Childhood Lead Poisoning Prevention 






20,702 


29,095 
100 


Environmental Health Training 


100 


Lead Exposure 


100 


100 


Air Pollution 


440 


440 


Asthma 


340 


340 


Other Environmental Disease Prevention 
Hanford Thyroid Disease Study 


1,530 
1.591 


1,530 
1.579 


Food and Drug 
Administration 


National Center for Toxicological Research 

Toxic Chemical Research 






3,899 


5.000 


Health Resources 
and Services 
Administration 


Bureau of Health Professions 

Health Professions Training and Education 


659 


556 


Bureau of Primary Health Care 

Water/Sanitation Projects Among Migrant 
and Rural People 


350 


350 


Maternal and Child Health Bureau 




9,700 


Prenatal and Infant Screening and Education 


8,000 


Indian Health 
Service 


Sanitation Facilities Construction 
Environmental Health Support 


75.000 
33,000 


75,000 
36.000 


National Institutes 
of Health 


Fogarty International Center 

Environmental Health Research 


117 


120 


National Center for Research Resources 

Environmental Health Research 


6,049 


5.937 



© 



DHHS Prevention Resources Inventory 



Table 6 (continued) 







(Dollars in ' 


rhousands) 


1 1 . Environmental Health (cont.) 


FY 1992 
Actual 


FY 1993 
Estimated 


National Institutes 
of Health (cont.) 


National Heart, Lung, and Blood Institute 




5,120 
1,996 


Asthma Research 


5,000 


National Asthma Education Program 


803 


National Institute of Dental Research 

Research on Environmental Health in Dentistry 


23 


23 


National Institute of Diabetes and Digestive 
and Kidney Diseases 






Other Environmental Health 
Toxicology 


35 
12 


38 
9 


National Institute of Environmental 
Health Sciences 


50,188 
62,609 


48,445 
64,061 

7,629 
14,639 

9,228 
62,000 


Applied Toxicological Research and Testing Program 
Biological Response to Environmental Agents 


Biometry and Risk Assessment 


9,905 


Environmental Health Centers 


14,479 


Training 


9,325 


Basic Research 


60,697 


National Institute on Aging 

Environmental Health 


3,072 


3,164 


National Library of Medicine 

Toxicology Information Program 


4,746 


4,936 


Administration for 
Children and 
Families 


Office of Community Services 






Rural Community Facilities 


2,098 


2,300 




Total 


$387,219 


$401,235 



ifflj 



Prevention '93/'94: Federal Programs and Progress 



Table 6 (continued) 



(Dollars in Thousands) 



1 2. Food and Drug Safety 


FY 1992 
Actual 


FY 1993 
Estimated 


Food and Drug 
Administration 


New Drug Review Process* 


$119,500 


$122,000 


Center for Food Safety and Applied Nutrition 

Enhanced Seafood Safety 

Monitoring the Food Supply for Pesticides 

Salmonella Enteritidis Information 


43,700 

35.455 

450 


43,000 
36,000 





Office of Regulatory Affairs/Center 
for Drug Evaluation and Research 




6,100 


Postmarketing Surveillance 


5,945 


National Institutes 
of Health 


National Institute of General Medical Sciences 

Food and Drug Safety 


2.652 


2.725 


National Institute on Aging 

Food and Drug Safety 


2,960 


2,960 


Total 


$210,662 


$212,785 


'Funded by CDER, CBER, and ORA. 



ffif 



DHHS Prevention Resources Inventory 



Table 6 (continued) 







(Dollars in Thousands) 


13. Oral Health 




FY 1992 

Actual 


FY 1993 
Estimated 


Agency for Health 
Care Policy and 
Research 


Clinical Decision-Making 
Outcomes of Dental Care 


$650 
790 


$506 

851 


Centers for 
Disease Control 
and Prevention 


National Center for Prevention Services 

Dental Caries Prevention Community-Based Education 
Fluoride Research 


22 
10 


27 


19 


Oral Cancer Control and Prevention 


21 


21 


Oral Cancer Prevention and Control Education 


15 


49 


Oral Cancer Prevention — Smokeless Tobacco 


5 


5 


Oral Health Care: Risk Communication Information 


182 


5 


Oral Health Care: Training and Technical Assistance 

Oral Health Surveillance with WHO 
in Hispanic Communities 


429 


479 
6 


13 


Oral Health Surveillance in States 


76 


48 


Training to IHS and Tribal Personnel 


14 


14 


Training on Water Fluoride 


39 


46 
11 


Water Fluoridation 


109 


Health Resource 
and Services 
Administration 


Bureau of Health Professions 


3,253 
4,900 


3,600 
5,000 


Health Professions Education 


Uncompensated Care — Dental Schools 


Bureau of Primary Health Care 




20,000 


Oral Health Promotion and Disease Prevention 


17,129 


Maternal and Child Health Bureau 






Maternal and Child Health Program 


500 


500 


Indian Health 
Service 


American Indian Dental Health 
Clinical Dental Caries Prevention 


7,000 

100 

1,000 


7,500 
200 


IHS Oral Health Personnel 


1,000 

125 

8,000 

20,000 

100 


Interagency Agreement with Administration for Children, 
Youth, and Families 


125 


Oral Health Promotion and Disease Prevention 


8,000 


Oral Health Survey 


20,000 


Periodontal Disease Prevention 


100 



© 



Prevention '93/'94: Federal Programs and Progress 



Table 6 (continued) 



(Dollars in Thousands) 



FY 1992 FY 1993 
1 3. Oral Health (cont.) Actual Estimated 


National Institutes 
of Health 


National Center for Research Resources 

Oral Health Research 






1.008 


990 


National Institute of Dental Research 

Research on Epidemiology of Oral Health and Disease 


3,626 




3,626 


Research on Fluoride 


3,364 


3,364 


Research on Oral Cancer Etiology and Prevention 
Research on Other Oral Health 


1,311 


1,311 


5,429 


5,429 


Research on Prevention of Adult Teeth Loss 
Research on Prevention of Childhood Caries 
Research on Prevention and Control of Periodiodontitis 


3,513 


3,513 


4,030 
7,988 


4,030 

7,988 

984 


Research on Protective Sealants 


984 


Administration for 
Children and 
Families 


Administration on Children, Youth, and Families 




58,302 


Head Start 


46,238 


Health Care 

Financing 

Administration 


Medicaid 


627,000 


881,000 




Total 


$768,973 


$1,038,649 



© 



DHHS Prevention Resource: 



NVENTORY 



Table 6 (continued) 



(Dollars in Thousands) 



FY 1992 FY 1993 
14. Maternal and Infant Health Actual Estimated 


Agency for Health 
Care Policy and 
Research 


Infant Health and Maternal Effectiveness 
and Outcomes Research 


$4,163 



782 


Maternal and Infant Health Care and the Disadvantaged 


1,308 


Centers for 
Disease Control 
and Prevention 


National Center for Chronic Disease Prevention 
and Health Promotion 

Infant Health Initiative Cooperative Agreements 

Infant Mortality Prevention 


4,359 
2,337 




4,350 
2,340 


Health Resources 
and Services 
Administration 


Bureau of Primary Health Care 




50,000 


Primary Care Centers 


50,000 


Bureau of Health Professions 




8,230 


Health Professions Training and Education 


8,394 


Maternal and Child Health Bureau 

Maternal and Child Health Block Grant Program 
Maternal and Child Health Systems 


92,496 
27,000 


96,000 

27,939 

1,510 

502 

6,800 

9,700 

995 

79,325 


Maternal and Infant Health Data Collection 


1.500 


One-Stop Shopping 


1,030 


Prenatal Care 


6,554 


Prenatal and Infant Screening and Education 
Substance Abuse Services for Pregnant Women 
Healthy Start 


9,700 
995 

61,161 


Indian Health 
Service 


American Indian Maternal and Child Health 


307,375 
1,500 


331,348 
2,277 


Fetal Alcohol Syndrome 


National Institutes 
of Health 


Fogarty International Center 

Maternal and Infant Health Prevention Research 


902 




927 


National Center for Research Resources 

Maternal and Infant Health Prevention Research 


5,041 


4,948 


National Heart, Lung, and Blood Institute 

Basic Biology of Cardiac Development: Animal Studies 
Basic Development Biology of the Vessel Wall 






840 
1,123 



617 


Trial: Calcium To Prevent Preeclampsia 

Specialized Centers of Research in Respiratory Disorders 
of Neonates and Children 


1,500 


500 


2,000 


2,048 



Utf 



Prevention '93/'94: Federal Programs and Progress 



Table 6 (continued) 







(Dollars in 


Thousands) 


14. Maternal and Infant Health (cont.) 


FY 1992 
Actual 


FY 1993 

Estimated 


National Institutes 
of Health (cont.) 


National Institute of Arthritis and Musculosketal 
and Skin Diseases 


1,353 


1,413 


Infant Mortality Due to Inherited 
Connective Tissue Disorders 


National Institute of Child Health 
and Human Development 

Maternal and Child Health 


116,887 


119,118 


National Institute of Dental Research 

Research on Maternal and Infant Oral Health 






341 


341 


National Institue of Nursing Research 

Low-Birth-Weight Prevention 

Nursing Care To Reduce Infant Mortality and Morbidity 


2,175 




2,300 


2,592 


2,800 
1,900 


Women's Health Research 


1.822 


National Institute on Drug Abuse 

Infant Health 


4,200 


4,500 


National Institute of Diabetes and Digestive 
and Kidney Diseases 


53,000 


54.500 


Maternal and Infant Health 


National Institute of Environmental 
Health Science 




7,000 


Environmental Effects on Early Pregnancy 


7,000 


National Institute of Mental Health 

Mental Health Factors Contributing to Infant Mortality/ 
Low Birth Weight 






331 


341 


Substance Abuse 
and Mental Health 
Services 
Administration 


Residential Treatment Programs for Pregnant 
and Postpartum Women 

Residential Treatment Program for Women and Children 





24,594 


10,000 


24,044 


Administration for 
Children and 
Families 


Administration on Children, Youth and Families 

Head Start Parent and Child Centers 


31,200 




32.448 


Office of Community Services 

Social Services Block Grant 


+ 


+ 


Office of Refugee Resettlement 

Medical Assistance 


2,000 
500 


2.000 
500 


Targeted Assistance 



rfh 



DHHS Prevention Resources Inventory 



Table 6 (continued) 



14. Maternal and Infant Health (cont.) 



(Dollars in Thousands) 



FY 1993 

Estimated 



Health Care 

Financing 

Administration 



Medicaid 



5,000,000 



Total 



$5,824,679 



5,600,000 



$6,508,937 



+Total amount spent on prevention category not known. In FY 1992, 20 States provided services to unmarried parents and 34 States pro- 
vided health-related services. 



reffe 



Prevention '93/'94: Federal Programs and Progress 



Table 6 (continued) 







(Dollars in Thousands) 


1 5. Heart Disease and Stroke 


FY 1992 
Actual 


FY 1993 
Estimated 


Agency for Health 
Care Policy and 
Research 


Patient Outcomes Research and Clinical Guidelines 
Development 


$8,270 


$7,570 


Centers for 
Disease Control 
and Prevention 


National Center for Chronic Disease Prevention 
and Health Promotion 






Cardiovascular Health Program 


14 


15 


Inter-Tribal Heart Disease Prevention Project 


85 


85 


Indian Health 
Service 


Inter-Tribal Heart Disease Prevention Project 


75 


75 


National Institutes 
of Health 


Fogarty International Center 




358 


Heart Disease and Stroke Prevention Research 


347 


National Center for Research Resources 

Heart Disease and Stroke Prevention Research 


9,981 




9,895 


National Heart, Lung, and Blood Institute 

Cardiovascular Health Study: Risk Factors 
in the Elderly 






4,338 


6.258 
6,000 
895 
2,566 
1,409 


Child and Adolescent Trial for Cardiovascular Health: 
School-Based Risk Reduction Interventions 


5,500 


Coronary Artery Risk Development in Young Adults: 
Prospective Epidemiological Stduy 

Initiative: Mechanisms Underlying Coronary Heart 
Disease in Blacks 

Initiative: Molecular Genetics of Hypertension in Humans 
and Animals 


4,945 
2,295 
1,314 


Specialized Centers of Research in Thrombosis 

Specialized Centers of Research in Coronary 

and Vascular Diseases, Heart Failure, and Congenital 
Heart Disease 


2,000 


2.048 


3,000 


3.072 


Specialized Centers of Research in Hypertension 

Specialized Centers of Research on Arteriosclerosis 

Strong Heart Study: Cardiovascular Disease 
among Native Americans 


2,000 
5,000 


2.048 
5,120 

512 

1.500 


500 


Trial: Postmenopausal Estrogen/Progestin 

Interventions: Effects on Cardiovascular Risk Factors 

Trial: Tamoxifen in Postmenopausal Women: 

Cardiovascular Risk and Events Coordinating Center 

Stroke Research 


2,554 

1,419 
5.000 


1.356 
5.120 



CS) 



DHHS Prevention Resources Inventory 



Table 6 (continued) 







(Dollars in 


thousands) 


15. Heart Disease and Stroke (cont.) 


FY1992 

Actual 


FY 1993 

Estimated 


National Institutes 
of Health (cont.) 


National Heart, Lung, and Blood Institute (cont.) 

Other Heart and Vascular Diseases Research 


39,640 


42,192 


Minority Research Training and 
Career Development Programs 


3,000 


3,072 
732 


Preventive Cardiology Academic Award: Curriculum 
Development for Minority Students 

National Heart Attack Alert Program 


850 


474 
1,161 


544 


National High Blood Pressure Education Program 


2,392 


National Institute on Aging 






Cardiovascular Disease and Aging Research 
Postmenopausal Estrogen/Progestin Interventions* 


20,136 
38 


20,740 

39 

3,950 


Stroke 


3,835 


National Institute of Arthritis and 
Musculoskeletal and Skin Diseases 






Postmenopausal Estrogen/Progestin Interventions* 


1,500 


75 


National Institute of Diabetes and Digestive 
and Kidney Diseases 






Nutrition Research 


36,950 


38,200 
3,300 


Postmenopausal Estrogen/Progestin Interventions* 


3,200 


National Institute of Nursing Research 






Reduction in Coronary Risk Factors 


724 


780 


National Institute on Drug Abuse 

Heart Disease/Stroke 


500 


500 


National Institute of Mental Health 






Research on Neuropsychological and 

Behavioral Aspects of Heart Disease and Stroke 


327 


330 


National Institute of Neurological 
Disorders and Stroke 




8,074 


Prevention of Strokes 


7,822 


Administration for 
Children and 
Families 


Office of Refugee Resettlement 

Medical Assistance 
Targeted Assistance 


1,050 
300 


1,050 
300 




Total 


$180,144 


$182,172 


'Program is funded by more 


than one institute. 







*2i 



Prevention '93/'94: Federal Programs and Progress 



Table 6 (continued) 



(Dollars in Thousands) 



FY 1992 FY 1993 
16. Cancer Actual Estimated 


Agency for Health 
Care Policy and 
Research 


Access to Preventive Services 

Guidelines on Mammography 

Patient Outcomes Research and 
Clinical Guideline Development 


$874 
1,196 

1,938 


$622 
969 

2.293 


Centers for 
Disease Control 
and Prevention 


National Center for Chronic Disease Prevention 
and Health Promotion 




Cancer Mortality Prevention 

Early Detection of Breast and Cervical Cancer 


1,300 


2,500 


40,000 


58,000 


Food and Drug 
Administration 


National Center for Toxicological Research 

Carcinogenic Chemical Exposure Research 


10,000 


10,000 


Health Resources 
and Services 
Administration 


Bureau of Health Professions 






Health Professions Training and Education 


516 


511 


Indian Health 
Service 


Cancer Prevention Project for American Indians 
Cancer Surveillance and Prevention Program 


100 
650 


100 


650 


Reducing Community Risk for Cancer 


5,000 


5,000 
1,000 


Women's Health Initiative 


1,000 


National Institutes 
of Health 


Fogarty International Center 






Cancer Prevention Research 


350 


361 


National Cancer Institute 


9,892 
60,298 


AIDS 


9,460 


Nutrition 


59,609 


Environmental Health 


285,000 


290.000 


Foundations 


305,953 


305,980 


National Center for Research Resources 

Cancer Prevention Research 




12,764 


13,006 


National Institute of Arthritis and 
Musculoskeletal and Skin Diseases 

Ultraviolet Radiation and Skin Diseases* 






750 


1,092 


National Institute of Diabetes and Digestive 
and Kidney Diseases 






Breast Cancer 

Other Cancer Research 


4,080 


4,200 


9,920 


1 1 ,800 



® 



DHHS Prevention Resources Inventory 



Table 6 (continued) 



(Dollars in Thousands) 



FY 1992 FY 1993 
16. Cancer (cont.) Actual Estimated 


National Institutes 
of Health (cont.) 


National Institute of Mental Health 

Psychoneuroimmunology and Psychotherapeutic 
Treatments of Cancer 


195 


202 


National Institute of Nursing Research 


78 


100 


Early Detection 


National Institute on Aging 

Aging and Cancer 


6,837 


7,040 


Administration for 
Children and 
Families 


Office of Refugee Resettlement 


2,000 


2,000 
200 


Medical Assistance 


Targeted Assistance 


200 


Health Care 

Financing 

Administration 


Medicaid 


25,000 
270,000 


25,000 
340,000 


Medicare 




Total 


$1,055,012 


$1,152,574 


'Program is funded by more than one institute. 



© 



Prevention '93/'94: Federal Programs and Progress 



Table 6 (continued) 



(Dollars in Thousands) 







FY 1992 


FY 1993 


17. Diabetes and Chroi c uisabling conditions 


Actual tsnMATED 


Agency for Health 
Care Policy and 
Research 


Community Models Project for Diabetes 
Prevention and Control 


$742 


$0 
1,265 


Effectiveness of Medical Services for Diabetes 
Health Services for the Chronically III 


1,396 


481 


666 
1,040 


Patient Outcomes Research and Clinical Guideline 
Development: Biliary and Respiratory 

Patient Outcomes Research and Clinical Guideline 
Development: Cataracts 


1,256 


1,458 


1.431 


Patient Outcomes Research and Clinical Guideline 
Development: Pain and Orthopedics 


3,833 


3,937 


Centers for 
Disease Control 
and Prevention 


National Center for Chronic Disease Prevention 
and Health Promotion 




60 

4.600 


Academic Centers for Prevention Research 

State-Based Programs to Reduce the Burden 
of Diabetes 


50 


4,800 


National Center for Environmental Health 

Fetal Alcohol Prevention 

Poverty-Associated Mental Retardation Prevention 

Prevention of Secondary Disabling Conditions in People 
with Existing Disabilities 


2,760 
1,130 


2.760 
1,130 


1,065 


6.050 
2,230 
8,709 


Spina Bifida Prevention Research 


2,230 
8,890 


State-Based Disabilities Prevention Programs 

Surveillance of Birth Defe